A comprehensive stroke center patient registry: advantages, limitations, and lessons learned

The Development of Simple Scoring System to Predict Urinary Tract Infection (UTI) in Patients with Stroke

Urinary tract infection is a frequent problem after stroke. Although prior scoring systems for UTI after stroke have been developed, we developed a simple scoring system for all types of stroke in our own. The study was designed on retrospective data. The population includes 1496 patients with stroke who had been admitted at the Neurology Department of Pyongyang Medical College Hospital between January 2010 and August 2019. The patients were diagnosed with confirmed CT and MRI. Urinary tract infection (UTI) was diagnosed through urine culture: more than 100,100 colony-forming units per millimeter in patients with signs and symptoms. The UTI prediction scoring system was developed by means of the variables available on admission. The variables with significant difference between the non-UTI group and the UTI group were age (non-UTI versus UTI, 56.4 ± 7.2 vs. 59.0 ± 12.8; p < 0.001), female (244 (24.2) vs. 176 (36.1), p < 0.001), 300 ≦ SI (smoking index) (16 (2.4) vs. 48 (12.0), p < 0.001), alcohol > 25 g/d (292 (29.0) vs. 184 (37.7), p < 0.001), poststroke hyperglycemia (120 (10.3) vs. 163 (33.4), p < 0.001), indwelling of urinary catheter (157 (15.6) vs. 351 (72.0), p < 0.001), GCS (Glasgow Coma Scale) on admission (11.2 ± 3.9 vs. 8.5 ± 4.0, p = 0.038), and WFNS (World Federation of Neurosurgeons) (in subarachnoid hemorrhage) on admission (2.9 ± 1.7 vs. 3.5 ± 1.5, p < 0.001). The UTI prediction score ranged from 0 to 8 and produced an AUC (area under curve) of 0.800. The optimal cutoff point was 2.5 (sensitivity 64.3% and specificity 79.9%). So, the score ≧ 3 was the optimal score for the prediction of UTI after stroke.

High resolution data modifies intensive care unit dialysis outcome predictions as compared with low resolution administrative data set

High resolution clinical databases from electronic health records are increasingly being used in the field of health data science. Compared to traditional administrative databases and disease registries, these newer highly granular clinical datasets offer several advantages, including availability of detailed clinical information for machine learning and the ability to adjust for potential confounders in statistical models. The purpose of this study is to compare the analysis of the same clinical research question using an administrative database and an electronic health record database. The Nationwide Inpatient Sample (NIS) was used for the low-resolution model, and the eICU Collaborative Research Database (eICU) was used for the high-resolution model. A parallel cohort of patients admitted to the intensive care unit (ICU) with sepsis and requiring mechanical ventilation was extracted from each database. The primary outcome was mortality and the exposure of interest was the use of dialysis. In the low resolution model, after controlling for the covariates that are available, dialysis use was associated with an increased mortality (eICU: OR 2.07, 95% CI 1.75-2.44, p<0.01; NIS: OR 1.40, 95% CI 1.36-1.45, p<0.01). In the high-resolution model, after the addition of the clinical covariates, the harmful effect of dialysis on mortality was no longer significant (OR 1.04, 95% 0.85-1.28, p = 0.64). The results of this experiment show that the addition of high resolution clinical variables to statistical models significantly improves the ability to control for important confounders that are not available in administrative datasets. This suggests that the results from prior studies using low resolution data may be inaccurate and may need to be repeated using detailed clinical data.

Sustaining the National Spinal Cord Injury Registry of Iran (NSCIR-IR) in a Regional Center: Challenges and Solutions

BACKGROUND

The National Traumatic Spinal Cord Injury Registry in Iran (NSCIR-IR), was implemented initially in three hospitals as a pilot phase from 11 Oct 2015 to 19 Jun 2016 and has been active in eight centers from 19 Jun 2016. Poursina Hospital, a trauma care referral center in Rasht, Guilan Province of Iran is one of the registry sites, and has been involved in registering eligible patients since 1 Jan 2016. This study aimed to identify the challenges and solutions for sustaining the NSCIR-IR in a regional center.

METHODS

This was a mixed-methods study. For the quantitative analysis, a retrospective observational design was used to measure case capture or case identification rate, mapping cases in the registry against those eligible for registry inclusion amongst the register of hospital admissions. For the qualitative component, data was collected using focus group discussions and semi-structured interviews, followed by thematic analysis.

RESULTS

From 19 Jun 2016 to 24 Jan 2018, the proportion of case capture (case identification rate) was 17%. The median time between case identification and data entry to the system was 30.5 d (range: 2 to 193 d). Thematic analysis identified a lack of trained human resources as the most important cause of low case identification rate and delay in data completion.

CONCLUSION

Recruitment and education to increase trained human resources are needed to improve case capture, the timeliness of data input and registry sustainability in a regional participating site.

Utilizing the Axon Registry® for quality improvement

In 2015, the American Academy of Neurology began development of a clinical quality data registry now known as the Axon Registry®. The data collected by the Axon Registry and reported back to participants include performance on a number of quality measures relevant to neurology practice. While the Axon Registry may serve any number of needs for neurology practices, the essential function of the registry is to inform neurologists regarding the quality of their care and provide them with a tool to establish not only performance baselines but progress toward improved quality of care. This article includes 2 case studies of how the Axon Registry has been implemented in neurology practices to date. In the future, implementation of patient-reported outcome data and additional outcome measures will be necessary to expand the reach and effectiveness of the Axon Registry as a quality improvement tool.

The CANadian Pediatric Weight management Registry (CANPWR): lessons learned from developing and initiating a national, multi-centre study embedded in pediatric clinical practice

Background

There is increasing recognition of the value of “real-world evidence” in evaluating health care services. Registry-based, observational studies conducted in clinical settings represent a relevant model to achieve this directive. Starting in 2010, we undertook a longitudinal, observational study (the CANadian Pediatric Weight management Registry [CANPWR]), which is embedded in 10 multidisciplinary, pediatric weight management clinics across Canada. The objective of this paper was to share the lessons our team learned from this multi-centre project.

Methods

Data sources included a retrospective review of minutes from 120 teleconferences with research staff and investigators, notes taken during clinical site visits made by project leaders, information from quality control processes to ensure data accuracy and completeness, and a study-specific survey that was sent to all sites to solicit feedback from research team members (n = 9). Through an iterative process, the writing group identified key themes that surfaced during review of these information sources and final lessons learned were developed.

Results

Several key lessons emerged from our research, including the (1) value of pilot studies and central research coordination, (2) need for effective and regular communication, (3) importance of consensus on determining outcome measures, (4) challenge of embedding research within clinical practice, and (5) difficulty in recruiting and retaining participants. The sites were, in spite of these challenges, enthusiastic about the benefits of participating in multi-centre collaborative studies.

Conclusion

Despite some challenges, multi-centre observational studies embedded in pediatric weight management clinics are feasible and can contribute important, practical insights into the effectiveness of health services for managing pediatric obesity in real-world settings.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1208-6) contains supplementary material, which is available to authorized users.

Factor VIII Level is Not Modifiable by Improved Glycemic Control in Patients with Ischemic Stroke

AIMS

To determine whether the degree of glycemic control was related to change in Factor VIII (FVIII) level in patients with acute ischemic stroke (AIS).

METHODS

From our stroke registry, all AIS patients admitted between 07/2008-05/2014 with baseline HbA1c and FVIII levels were eligible. Of these, patients with follow-up HbA1c and FVIII levels post-discharge were included. Elevation in FVIII was defined as level >150%. Diabetic control was categorized according to HbA1c levels:uncontrolled (>7.1%), controlled (5.7-7.0%), and normal (<5.7%) HbA1c and FVIII levels were further analyzed for evidence of a correlation as continuous variables.

RESULTS

Among 1,631 AIS cases, 63 patients met inclusion criteria. Of these, 21 patients (33.3%) had uncontrolled diabetes, 27 patients (42.8%) had controlled diabetes, and 15 patients (23.4%) had normoglycemia. Baseline demographic characteristics differed only for history of hyperlipidemia (57.1% uncontrolled, 25.9% controlled, 26.7% normal, p=0.0443). Time between baseline and follow-up measures of both FVIII and HbA1c did not differ between groups (p=0.0812 and p=0.6969, respectively). There was no association between HbA1C group and FVIII level at baseline (p=0.2197) nor between change in HbA1c and change in FVIII from baseline to follow-up (r=0.0147, p=0.9092). Additionally, no statistically significant level at baseline or follow-up.

CONCLUSIONS

While hyperglycemia and FVIII level are associated in the acute phase of AIS, long-term glycemic control before or subsequent to AIS was unrelated to FVIII level. Our results suggest that these stroke risk factors are independent of each other and that FVIII level cannot be modified by controlling diabetes.

Safety and Efficacy of Acute Clopidogrel Load in Patients with Moderate and Severe Ischemic Strokes

Objective. To study the safety and efficacy of a clopidogrel loading dose in patients with moderate and severe acute ischemic strokes. Background. The safety of clopidogrel loading has been extensively investigated in patients with minor strokes and transient ischemic attacks. Methods. Acute ischemic stroke patients presenting consecutively to our center from 07/01/08 to 07/31/13 were screened. Clopidogrel loading was defined as at least 300 mg dose (with or without aspirin) given within 6 hours of admission. We compared outcomes in patients with baseline NIHSS > 3 with and without clopidogrel loading. Results. Inclusion criteria were met for 1011 patients (43.6% females, 69.1% black, median age 63). Patients with clopidogrel loading had lower baseline NIHSS than patients who were not loaded (8 versus 9, p = 0.005). The two groups had similar risk for hemorrhagic transformation (p = 0.918) and symptomatic hemorrhage (p = 0.599). Patients who were loaded had a lower rate of neurological worsening (38.9% versus 48.3%, p = 0.031) and less in-hospital mortality (4.3% versus 13.4%, p = 0.001) compared to those who were not loaded. The likelihood of having a poor functional outcome did not differ between the two groups after adjusting for NIHSS on admission (OR = 0.71, 95% CI 0.4633–1.0906, p = 0.118). Conclusion. Clopidogrel loading dose was not associated with increased risk for hemorrhagic transformation or symptomatic intracranial hemorrhage in our retrospective study and was associated with reduced rates of neuroworsening following moderate and severe stroke.

Left Atrial Enlargement on Transthoracic Echocardiography Predicts Left Atrial Thrombus on Transesophageal Echocardiography in Ischemic Stroke Patients

Background. Transesophageal echocardiogram (TEE) is superior to transthoracic echocardiogram (TTE) in detecting left atrial thrombus (LAT), a risk factor for stroke, but is costly and invasive, carrying a higher risk for complications. Aims. To determine the utility of using left atrial enlargement (LAE) on TTE to predict LAT on TEE. Methods. AIS patients who presented in 06/2008–7/2013 and underwent both TTE and TEE were identified from our prospective stroke registry. Analysis consisted of multivariate logistic regression with propensity score adjustment and receiver operating characteristic (ROC) area under the curve (AUC) analyses. Results. 219 AIS patients underwent both TTE and TEE. LAE on TTE was detected in 113 (51.6%) of AIS patients. Patients with LAE on TTE had higher proportion of LAT on TEE (8.4% versus 1.0%, p = 0.018). LAE on TTE predicted increased odds of LAT on TEE (OR = 8.83, 95% CI 1.04–74.83, p = 0.046). The sensitivity and specificity for LAT on TEE by LAE on TEE were 88.89% and 52.20%, respectively (AUC = 0.7054, 95% CI 0.5906–0.8202). Conclusions. LAE on TTE can predict LAT detected on TEE in nearly 90% of patients. This demonstrates the utility of LAE on TTE as a potential screening tool for LAT, potentially limiting unneeded costs and complications associated with TEE.

Effect of aphasia on acute stroke outcomes

OBJECTIVE

To determine the independent effects of aphasia on outcomes during acute stroke admission, controlling for total NIH Stroke Scale (NIHSS) scores and loss of consciousness.

METHODS

Data from the Tulane Stroke Registry were used from July 2008 to December 2014 for patient demographics, NIHSS scores, length of stay (LOS), complications (sepsis, deep vein thrombosis), and discharge modified Rankin Scale (mRS) score. Aphasia was defined as a score >1 on question 9 on the NIHSS on admission and hemiparesis as >1 on questions 5 or 6.

RESULTS

Among 1,847 patients, 866 (46%) had aphasia on admission. Adjusting for NIHSS score and inpatient complications, those with aphasia had a 1.22 day longer LOS than those without aphasia, whereas those with hemiparesis (n = 1,225) did not have any increased LOS compared to those without hemiparesis. Those with aphasia had greater odds of having a complication (odds ratio [OR] 1.44, confidence interval [CI] 1.07-1.93, p = 0.0174) than those without aphasia, which was equivalent to those having hemiparesis (OR 1.47, CI 1.09-1.99, p = 0.0137). Controlling for NIHSS scores, aphasia patients had higher odds of discharge mRS 3-6 (OR 1.42 vs 1.15).

CONCLUSION

Aphasia is independently associated with increased LOS and complications during the acute stroke admission, adding $2.16 billion annually to US acute stroke care. The presence of aphasia was more likely to produce a poor functional outcome than hemiparesis. These data suggest that further research is necessary to determine whether establishing adaptive communication skills can mitigate its consequences in the acute stroke setting.

Intravenous Tissue Plasminogen Activator for Wake-Up Stroke: A Propensity Score-Matched Analysis

GOAL

To evaluate the safety and efficacy of intravenous (IV) tissue plasminogen activator (tPA) in the treatment of wake-up stroke (WUS) using propensity score (PS) analysis.

MATERIALS AND METHODS

Consecutive acute ischemic stroke patients meeting inclusion criteria were retrospectively identified from our stroke registry between July 2008 and May 2014, and classified as stroke onset less than or equal to 4.5 hours treated with tPA (control; n = 369), tPA-treated WUS (n = 46), or nontreated WUS (n = 154). The primary outcome of interest for safety was symptomatic intracerebral hemorrhage (sICH), defined as parenchymal hemorrhage associated with a greater than or equal to 4-point increase in National Institutes of Health Stroke Scale (NIHSS) score. Multivariate logistic regression with adjustment for confounders and PS for receiving IV tPA assessed outcomes, along with PS-matched average treatment effect on the treated (ATT).

FINDINGS

No significant difference was found in rates of sICH between tPA-treated WUS, nontreated WUS, and controls (2.2%, .7%, and 3%, respectively), or in the odds of sICH between tPA-treated WUS and controls (OR = .53, 95% CI = .06-4.60, P = .568). Among WUS patients, tPA treatment was significantly associated with higher odds of good functional outcome in fully adjusted analyses (OR = 7.22, 95% CI = 2.28-22.88, P = .001). The ATT of tPA for WUS patients demonstrated a significantly greater decrease in NIHSS score at discharge when compared to nontreated WUS patients (-4.32 versus -.34, P = .032).

CONCLUSIONS

Comparable rates of sICH between treated WUS and stroke onset less than or equal to 4.5 hours treated with tPA suggest that tPA may be safely used to treat WUS. Superior outcomes for tPA-treated versus nontreated WUS subjects may suggest clinical efficacy of the treatment.

Early Neurologic Deterioration after Stroke Depends on Vascular Territory and Stroke Etiology

BACKGROUND AND PURPOSE

Early neurologic deterioration (END) occurs in up to one-third of patients with ischemic stroke and is associated with poor outcomes. The purpose of the present study was to determine which stroke etiologies and vascular distributions pose a greater threat of END in stroke patients.

METHODS

Using a single-center registry of prospectively maintained clinical data, adult ischemic stroke patients admitted (July 2008 to June 2014) within 48 hours of symptom onset were evaluated according to stroke etiology and vascular distribution using diffusion-weighted MRI. Major stroke etiologies were divided into cardioembolic, large vessel, small vessel, other, unknown source, and multiple possible etiologies. END was defined as a worsening of 2 or more points on the National Institutes of Health Stroke Scale during a 24-hour period of hospitalization. Crude and backward stepwise regression models were generated to associate stroke etiology and vascular distribution with END.

RESULTS

Of the included 961 patients (median age 65 years, 47% female, 72% non-White), 323 (34%) experienced END. Strokes involving the internal carotid artery (ICA) were associated with a threefold higher odds of END in stepwise regression models (OR 3.0, 95% CI 1.4-6.6, P=0.006). Among stroke etiologies, those with unclear mechanisms had the lowest odds of END in the fully adjusted model (OR 0.6, 95% CI 0.4-1.0, P=0.029).

CONCLUSIONS

In our single-center cohort of patients, ICA infarctions were independently associated with END whereas strokes of unknown etiology were least often associated with END. Larger cohorts are necessary to determine which steps, if any, can be taken to prevent END in these vulnerable populations.

Time to Neurological Deterioration in Ischemic Stroke

BACKGROUND

Neurological deterioration (ND) is common, with nearly one-half of ND patients deteriorating within the first 24 to 48 hours of stroke. The timing of ND with respect to ND etiology and reversibility has not been investigated.

METHODS

At our center, we define ND as an increase of 2 or more points in the National Institutes of Health Stroke Scale (NIHSS) score within 24 hours and categorize etiologies of ND according to clinical reversibility. ND etiologies were considered non-reversible if such causes may have produced or extended any areas of ischemic neurologic injury due to temporary or permanent impairment in cerebral perfusion.

RESULTS

Seventy-one of 350 ischemic stroke patients experienced ND. Over half (54.9%) of the patients who experienced ND did so within the 48 hours of last seen normal. The median time to ND for non-reversible causes was 1.5 days (IQR 0.9, 2.4 days) versus 2.6 days for reversible causes (IQR 1.4, 5.5 days, p=0.011). After adjusting for NIHSS and hematocrit on admission, the log-normal survival model demonstrated that for each 1-year increase in a patient's age, we expect a 3.9% shorter time to ND (p=0.0257). In addition, adjusting for age and hematocrit on admission, we found that that for each 1-point increase in the admission NIHSS, we expect a 3.1% shorter time to ND (p=0.0034).

CONCLUSIONS

We found that despite having similar stroke severity and age, patients with nonreversible causes of ND had significantly shorter median time to ND when compared to patients with reversible causes of ND.

A Model for Predicting Persistent Elevation of Factor VIII among Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Elevated levels of coagulation factor VIII (FVIII) may persist independent of the acute-phase response; however, this relationship has not been investigated relative to acute ischemic stroke (AIS). We examined the frequency and predictors of persistently elevated FVIII in AIS patients.

METHODS

AIS patients admitted between July 2008 and May 2014 with elevated baseline FVIII levels and repeat FVIII levels drawn for more than 7 days postdischarge were included. The patients were dichotomized by repeat FVIII level for univariate analysis at 150% and 200% activity thresholds. An adjusted model was developed to predict the likelihood of persistently elevated FVIII levels.

RESULTS

Among 1616 AIS cases, 98 patients with elevated baseline FVIII had repeat FVIII levels. Persistent FVIII elevation was found in more than 75% of patients. At the 150% threshold, the prediction score ranged from 0 to 7 and included black race, female sex, prior stroke, hyperlipidemia, smoking, baseline FVIII > 200%, and baseline von Willebrand factor (vWF) level greater than 200%. At the 200% threshold, the prediction score ranged from 0-5 and included female sex, prior stroke, diabetes mellitus, baseline FVIII level greater 200%, and baseline vWF level greater than 200%. For each 1-point increase in score, the odds of persistent FVIII at both the 150% threshold (odds ratio [OR] = 10.4, 95% confidence interval [CI] 1.63-66.9, P = .0134) and 200% threshold (OR = 10.2, 95% CI 1.82-57.5, P = .0083) increased 10 times.

CONCLUSION

Because an elevated FVIII level confers increased stroke risk, our model for anticipating a persistently elevated FVIII level may identify patients at high risk for recurrent stroke. FVIII may be a target for secondary stroke prevention.

Recurrent posterior strokes in inflammatory bowel disease patients

Objective. To describe the stroke characteristics of patients with a history of inflammatory bowel disease (IBD). Background. A hypercoagulable state associated with IBD has been frequently implicated as a risk factor for ischemic stroke. Variable mechanisms and infrequent occurrence limit prospective clinical research on the association between IBD and stroke. Methods. We retrospectively reviewed consecutive patients with acute ischemic stroke presenting to our medical center from 7/2008 to 9/2013. Patients with a history of IBD were identified. Clinical variables were abstracted from our prospective stroke registry. Results. Over the period of five years we identified only three patients with a documented history of IBD. Each of these patients presented three times to our hospital with new strokes. Patients presented outside the window for intravenous tPA treatment on 8/9 admissions. Each one of our patients had posterior strokes on at least two separate occasions. Hypercoagulation panel showed elevated factor VIII with or without concomitant elevation of Von Willebrand factor (vWF) during almost every admission (8/9 admissions). Only one admission was associated with IBD flare. Conclusion. The association between IBD and posterior strokes is a novel finding. Factor VIII elevation may serve as a biomarker of a peristroke hypercoagulable state in patients with IBD.

Prolonged Emergency Department Length of Stay as a Predictor of Adverse Outcomes in Patients with Intracranial Hemorrhage

Objectives

Extended time in the emergency department (ED) has been related to adverse outcomes among stroke patients. We examined the associations of ED nursing shift change (SC) and length of stay in the ED with outcomes in patients with intracerebral hemorrhage (ICH).

Methods

Data were collected on all spontaneous ICH patients admitted to our stroke center from 7/1/08–6/30/12. Outcomes (frequency of pneumonia, modified Rankin Scale (mRS) score at discharge, NIHSS score at discharge, and mortality rate) were compared based on shift change experience and length of stay (LOS) dichotomized at 5 hours after arrival.

Results

Of the 162 patients included, 60 (37.0%) were present in the ED during a SC. The frequency of pneumonia was similar in the two groups. Exposure to an ED SC was not a significant independent predictor of any outcome. LOS in the ED ≥5 hours was a significant independent predictor of discharge mRS 4–6 (OR 3.638, 95% CI 1.531–8.645, and P = 0.0034) and discharge NIHSS (OR 3.049, 95% CI 1.491–6.236, and P = 0.0023) but not death.

Conclusions

Our study found no association between nursing SC and adverse outcome in patients with ICH but confirms the prior finding of worsened outcome after prolonged length of stay in the ED.

A simple prediction score for developing a hospital-acquired infection after acute ischemic stroke

BACKGROUND

Hospital-acquired infections (HAIs) are a major cause of morbidity and mortality in acute ischemic stroke patients. Although prior scoring systems have been developed to predict pneumonia in ischemic stroke patients, these scores were not designed to predict other infections. We sought to develop a simple scoring system for any HAI.

METHODS

Patients admitted to our stroke center (July 2008-June 2012) were retrospectively assessed. Patients were excluded if they had an in-hospital stroke, unknown time from symptom onset, or delay from symptom onset to hospital arrival greater than 48 hours. Infections were diagnosed via clinical, laboratory, and imaging modalities using standard definitions. A scoring system was created to predict infections based on baseline patient characteristics.

RESULTS

Of 568 patients, 84 (14.8%) developed an infection during their stays. Patients who developed infection were older (73 versus 64, P < .0001), more frequently diabetic (43.9% versus 29.1%, P = .0077), and had more severe strokes on admission (National Institutes of Health Stroke Scale [NIHSS] score 12 versus 5, P < .0001). Ranging from 0 to 7, the overall infection score consists of age 70 years or more (1 point), history of diabetes (1 point), and NIHSS score (0-4 conferred 0 points, 5-15 conferred 3 points, >15 conferred 5 points). Patients with an infection score of 4 or more were at 5 times greater odds of developing an infection (odds ratio, 5.67; 95% confidence interval, 3.28-9.81; P < .0001).

CONCLUSION

In our sample, clinical, laboratory, and imaging information available at admission identified patients at risk for infections during their acute hospitalizations. If validated in other populations, this score could assist providers in predicting infections after ischemic stroke.

New Thrombotic Events in Ischemic Stroke Patients with Elevated Factor VIII

Background. Heightened levels of Factor VIII (FVIII) have been associated with both arterial and venous thrombosis. While elevated FVIII is common during acute ischemic stroke (AIS), whether elevated FVIII confers an increased risk for recurrent thrombotic events (RTEs) following AIS has not been previously explored. Methods. Consecutive AIS patients who presented to our center between July 2008 and September 2013 and had FVIII measured during admission were identified from our stroke registry. Baseline characteristics and the occurrence of RTE (recurrent or progressive ischemic stroke, DVT/PE, and MI) were compared in patients with and without elevated FVIII levels. Results. Of the 298 patients included, 203 (68.1%) had elevated FVIII levels. Patients with elevated FVIII had higher rates of any in-hospital RTE (18.7% versus 8.4%, P = 0.0218). This association remained after adjustment for baseline stroke severity and etiology (OR 1.01, 95% CI 1.00–1.01, P = 0.0013). Rates of major disability were also higher in patients who experienced a RTE (17.8% versus 3.2%, P < 0.0001). Conclusion. A significantly higher frequency of in-hospital RTEs occurred in AIS patients with elevated FVIII. The occurrence of such events was associated with higher morbidity. Further study is indicated to evaluate whether FVIII is a candidate biomarker for increased risk of RTEs following AIS.

The impact of absent A1 segment on ischemic stroke characteristics and outcomes

BACKGROUND

A1 segment is the proximal portion of anterior cerebral artery. Absence of the A1 segment can compromise anterior cerebral collateral blood flow. Few studies have examined the association of an absent A1 segment and ischemic stroke outcome. We sought to determine the association between A1 absence and affected vessel territory, stroke volume, and outcomes among patients with acute ischemic stroke (AIS).

METHODS

A retrospective review of prospectively identified patients with AIS from July 2008 to March 2013 was performed. Patients without intracranial vascular imaging were excluded. We compared patients with absent A1 to patients with bilateral A1 segments in terms of demographics, stroke severity (as measured by National Institute of Health Stroke Scale [NIHSS]), vascular distribution, and in-hospital mortality using the chi-square test and logistic regression.

RESULTS

Of the 1146 patients with AIS and intracranial vascular imaging, 5.9% patients (n = 68) had absent A1. Compared with other AIS patients, those with absent A1 were older (65 vs. 63 years old, respectively, P = .016). There was no difference between groups in terms of the vascular distribution or the side of the stroke. The median volume of the infracted tissue was similar across the groups even when it was stratified according to the Treatment of Acute Stroke Trial classification. Patients with an absent A1 had twice higher odds of in-hospital mortality (odds ratio, 2.4; 95% confidence interval, 1.1-5.2; P = .028); however, significance was lost after adjusting to age, NIHSS at baseline, and glucose on admission. Other outcome measures were similar across the groups.

CONCLUSIONS

In our sample, patients with an absent A1 segment did not have a specific vascular distribution, larger infarct volume, or worse outcomes.

Trimming the fat in acute ischemic stroke: an assessment of 24-h CT scans in tPA patients

BACKGROUND

International management of acute ischemic stroke patients treated with intravenous tissue plasminogen activator frequently includes 24-h head imaging. These recommendations stem from the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial protocol regarding the risk of intracerebral hemorrhage post-tissue plasminogen activator administration. Follow-up computed tomography scans on select patients, however, may not effect clinical management, resulting in unnecessary radiation exposure and healthcare costs.

AIMS

Our study questions the utility of routine 24-h computed tomography imaging and looks at the National Institute of Health Stroke Scale as a possible clinical screen for selecting candidates for 24-h imaging. Such a tool would result in decreased radiation exposure to the patient and decreased cost to the hospital.

METHODS

Consecutive patients with acute ischemic stroke given intravenous tissue plasminogen activator between June 2008 and December 2011 were retrospectively identified and dichotomized based on change in 24-h National Institute of Health Stroke Scale from baseline. Initial analysis compared patients with National Institute of Health Stroke Scale worsening to those without worsening. Subsequent analysis was limited to patients with a baseline National Institute of Health Stroke Scale ≤10. Baseline demographics and medical history, baseline and 24-h computed tomography findings, medical and/or surgical orders within six-hours of imaging, and antithrombotic administration within 24-48-h postintravenous tissue plasminogen activator were compared between the two groups.

RESULTS

Two-hundred patients met inclusion criteria: No 24-h National Institute of Health Stroke Scale worsening (n = 167) vs. 24-h National Institute of Health Stroke Scale worsening (n = 33). No baseline demographic or admission data differed significantly between the two groups. Patients without 24-h National Institute of Health Stroke Scale worsening had significantly lower incidence of hemorrhagic infarction (10·8% vs. 31·3%, P = 0·0014) on follow-up imaging. Less than 2% of all patients without 24-h National Institute of Health Stroke Scale worsening had a parenchymal hematoma. No patient with baseline National Institute of Health Stroke Scale ≤10 and without 24-h National Institute of Health Stroke Scale worsening had parenchymal hematoma. Patients with 24-h worsening were significantly less likely to receive timely antithrombotic therapy (60·6% vs. 77·8%, odds ratio 0·44, 95% confidence interval 0·20-0·96).

CONCLUSIONS

Our results demonstrate that routine 24-h computed tomography scan in patients without 24-h National Institute of Health Stroke Scale worsening (especially those with baseline National Institute of Health Stroke Scale ≤10) is less likely to yield information that results in a deviation from standard acute stroke care. No patient without worsening and baseline National Institute of Health Stroke Scale ≤10 had parenchymal hematoma on 24-h computed tomography. Application of the National Institute of Health Stroke Scale to distinguish patients who should have 24-h follow-up imaging from those who will not benefit is a potential avenue for improving utilization of resources and warrants further study.

Inpatient rehabilitation centers and concern for increasing volume of ischemic stroke patients requiring rehabilitation

OBJECTIVES

To determine whether prolonged length of stay (pLOS) in ischemic stroke is related to delays in discharge disposition arrangement.

METHODS

We designed a retrospective study to compare patients with acute ischemic stroke who experienced pLOS to those who did not experience pLOS. Patients who have had acute ischemic stroke between July 2008 and December 2010 were included unless they arrived >48 hours after time last seen normal, had an unknown last seen normal, or experienced an in-hospital stroke. pLOS was defined in our prospective stroke registry (before the generation of this research question) as hospitalization extended for ≥ 24 hours more than necessary to determine neurologic stability and next level of care/disposition for a given patient. We characterized the frequency of each cause of pLOS and further investigated the destinations that were more frequently associated with pLOS among patients with delay resulting from arranging discharge disposition.

RESULTS

Of the 274 patients included, 106 (31.9%) had pLOS. Reasons for pLOS were discharge disposition (48.1%), non-neurologic medical complications (36.8%), delays in imaging studies (20.8%), awaiting procedure (10.4%), and neurologic complications (9.4%). Among patients with pLOS caused by delayed disposition, more than half were awaiting placement in an inpatient rehabilitation facility.

CONCLUSIONS

For the majority of our patients, pLOS was caused by acquired medical complications and delayed disposition, most commonly inpatient rehabilitation. Further efforts are needed to prevent complications and further investigation is necessary to identify the factors that may contribute to delayed discharge to inpatient rehabilitation facilities, which may include delayed planning or heightened scrutiny of insurance companies regarding their beneficiaries.

The Impact of Myocardial Infarction vs. Pneumonia on Outcome in Acute Ischemic Stroke

The aim of this study was to examine the association between MI and PNA in the setting of acute ischemic stroke and patient outcome. Eligible patients were identified from a prospectively collected stroke registry and included if transthoracic echocardiography (TTE) was performed during their inpatient stay. 426 patients met inclusion criteria (mean age 64, 73% Black, 48% female). Twenty-one patients (4.9%) experienced an MI. Patients who later suffered a MI initially presented with more severe strokes (median NIHSS 7 vs. 5, p=0.014). More patients in the MI group experienced pneumonia (26% vs. 9%, p=0.004). After adjusting for age, baseline glucose and NIHSS, the odds of in-hospital mortality for patients with MI was 3 times that of those without MI (OR 3.2 95% CI 1.1-9.7, p=0.036). When adjustment was made for pneumonia, age, baseline glucose and NIHSS, MI was no longer significantly related to in-hospital mortality (OR 2.5 95% CI 0.8-8.2, p=0.131). In our sample, while MI was significantly associated with in-hospital mortality, this association was attenuated after adjusting for presence of pneumonia. Our findings raise the question as to whether the prevention of pneumonia could improve in-hospital mortality among patients who experience MI in the setting of ischemic stroke.

Cardiac Function and Short-Term Outcome in Patients with Acute Ischemic Stroke: A Cross-Sectional Study

Few studies have investigated the relationship between left ventricular ejection fraction (LVEF) and functional outcome in ischemic stroke patients. The purpose of this study was to determine if a low LVEF in ischemic stroke was associated with functional outcome. A cross-sectional study was performed on ischemic stroke patients admitted to a single academic stroke center from June 2008 to December 2010. LVEF was determined using transthoracic or transesophageal echocardiography. Patients were categorized into three LVEF groups: severely low (<30%), moderately low (30-49%), and normal (>50%). Baseline demographics, in-hospital complications, and early outcomes were compared among LVEF groups using Chi-square, Wilcoxon rank sum, and logistic regression.590 patients met inclusion criteria (median age 65, 74% African American, 48% female). LVEF was normal in 79.8%, moderately low in 10.8%, and severely low in 9.3%. A smaller proportion of patients with severely low LVEF appeared to have good functional outcome compared to other groups (26% vs. 40% vs. 45%, p=0.028); however, this relationship was not significant after adjusting for age, baseline National Institute of Health Stroke Scale score and admission glucose (OR 0.6, 95% CI 0.3-1.3, p=0.216). Low LVEF was not an independent, significant predictor of short-term functional outcomes in ischemic stroke patients.

Hospital-Acquired Infection Underlies Poor Functional Outcome in Patients with Prolonged Length of Stay

Introduction

Prolonged length of stay (pLOS) following ischemic stroke inflates cost, increases risk for hospital-acquired complications, and has been associated with worse prognosis.

Methods

Acute ischemic stroke patients admitted between July 2008 and December 2010 were retrospectively analyzed for pLOS, defined as a patient stable for discharge hospitalized for an additional ≥24 hours.

Results

Of 274 patients included, 106 (38.7%) had pLOS (median age 65 years, 60.6% female, 69.0% black). Patients with pLOS had higher admission NIHSS than patients without pLOS (9 versus 5, P = 0.0010). A larger proportion of patients with pLOS developed an infection (P < 0.0001), and after adjusting for covariates, these patients had greater odds of poor short-term functional outcome (OR = 2.25, 95% CI 1.17–4.32, P = 0.0148). Adjusting for infection, the odds of patients with pLOS having poor short-term functional outcome were no longer significant (OR = 1.68, 95% CI 0.83–3.35, P = 0.1443).

Conclusions

The contraction of a hospital-acquired infection was a significant predictor of pLOS and a contributor of poor short-term outcome following an ischemic stroke. Whether the cause or the consequence of pLOS, hospital-acquired infections are largely preventable and a target for reducing length of stay.

A proposal for the classification of etiologies of neurologic deterioration after acute ischemic stroke

BACKGROUND

Neurologic deterioration (ND) occurs in one third of patients with ischemic stroke and contributes to morbidity and mortality in these patients. Etiologies of ND and clinical outcome according to ND etiology are incompletely understood.

METHODS

We conducted a retrospective investigation of all patients with ischemic stroke admitted to our center (July 2008 to December 2010), who were known to be last seen normal less than 48 hours before arrival. First-time episodes of ND during hospitalization were collected in which a patient experienced a 2-point increase or more in National Institutes of Health Stroke Scale score within a 24-hour period. Proposed etiologies of reversible ND include infectious, metabolic, hemodynamic, focal cerebral edema, fluctuation, sedation, and seizure, whereas new stroke, progressive stroke, intracerebral hemorrhage, and cardiopulmonary arrest were nonreversible.

RESULTS

Of 366 included patients (median age 65 years, 41.4% women, 68.3% black), 128 (34.9%) experienced ND (median age 69 years, 42.2% women, 68.7% black). Probable etiologies of ND were identified in 90.6% of all first-time ND events. The most common etiology of ND, progressive stroke, was highly associated with poor outcome but not death. Etiologies most associated with mortality included edema (47.8%), new stroke (50%), and intracerebral hemorrhage (42.1%).

CONCLUSIONS

In the present study, the authors identified probable etiologies of ND after ischemic stroke. Delineating the cause of ND could play an important role in the management of the patient and help set expectations for prognosis after ND has occurred. Prospective studies are needed to validate these proposed definitions of ND.

Acute decrease in serum magnesium level after ischemic stroke may not predict decrease in neurologic function

BACKGROUND

Higher serum levels of magnesium (Mg2+) may contribute to improved outcome following ischemic stroke, and this may be related to vessel recanalization. Patients with low or normal serum magnesium levels during the acute phase of ischemic stroke may be more susceptible to neurologic deterioration (ND) and worse outcomes.

METHODS

All patients who presented to our center within 48 hours of acute ischemic stroke (July 2008 to December 2010) were retrospectively identified. Patient demographics, laboratory values, and multiple outcome measures, including ND, were compared across admission serum Mg2+ groups and change in Mg2+ from baseline to 24-hour groups.

RESULTS

Three hundred thirteen patients met inclusion criteria (mean age: 64.8 years, 42.2% female, 64.0% black). Mg2+ groups at baseline were not predictive of poor functional outcome, death, or discharge disposition. Patients whose serum Mg2+ decreased during the first 24 hours of admission were also not at greater odds of ND or poor outcome measures compared with patients with unchanging or increasing Mg2+ levels.

CONCLUSIONS

Our results suggest that patients who have low Mg2+ at baseline or a reduction in Mg2+ 24 hours after admission are not at a higher risk of experiencing ND or poor short-term outcome. Ongoing prospective interventional trials will determine if hyperacute aggressive magnesium replacement affords neuroprotection in stroke.