GP.1 Changes in ischemic stroke presentations and associated workflow
                        during the first wave of the COVID-19 pandemic: A population study

Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program – a registry capturing stroke-related data on the entire Albertan population(4.3 million) – to identify all patients hospitalized with stroke in the pre-pandemic(01/01/2016-27/02/2020) and COVID-19 pandemic(28/02/2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy(EVT), adjusted for age, sex, comorbidities, and pre-admission care needs; and in workflow, stroke severity(National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped(weekly adjusted-incidence-rate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis(aIRR:0.49,0.44-0.56) or EVT(aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02,0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays(adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.

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Changes in ischemic stroke presentations and associated workflow during the first wave of the COVID-19 pandemic: A population study in Alberta, Canada

10.1101/2021.10.04.21264529 ◽

2021 ◽

Author(s):

Aravind Ganesh ◽

Jillian M Stang ◽

Finlay McAlister ◽

Oleksandr Shlakhter ◽

Jessalyn K Holodinsky ◽

...

Keyword(s):

Ischemic Stroke ◽

Population Level ◽

Stroke Care ◽

Population Based ◽

Entire Population ◽

Hospital Treatment ◽

Stroke Severity ◽

Care Needs ◽

Acute Therapy ◽

Treatment Delays

Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. There is a paucity of population-based data on these phenomena for stroke. We examined the effect of the COVID-19 pandemic on the presentation and treatment of ischemic stroke in an entire population. Methods: We used linked provincial administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program, a registry capturing stroke-related data on the entire population of Alberta(4.3 million), to identify all patients presenting with stroke in the pre-pandemic(1-January-2016 to 27-February-2020, n=19,531) and pandemic(28-February-2020 to 30-August-2020, n=2,255) periods. We examined changes in thrombolysis and endovascular therapy(EVT) rates, workflow, and in-hospital outcomes. Results: Hospitalizations/presentations for ischemic stroke dropped (weekly adjusted-incidence-rate-ratio[aIRR]:0.48, 95%CI:0.46-0.50, adjusted for age, sex, comorbidities, pre-admission care needs), as did population-level incidence of thrombolysis(aIRR:0.49,0.44-0.56) or EVT(aIRR:0.59,0.49-0.69). However, the proportions of presenting patients receiving acute therapies did not decline (e.g. thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02,0.75-1.38). Onset-to-door times were prolonged; EVT recipients experienced longer door-to-reperfusion times (median door-to-reperfusion:110-minutes, IQR:77-156 pre-pandemic vs 132.5-minutes, 99-179 during-pandemic; adjusted-coefficient:18.7-minutes, 95%CI:1.45-36.0). Hospitalizations were shorter but stroke severity and in-hospital mortality did not differ. Interpretation: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-hospital and in-hospital treatment delays. Our data can inform public health messaging and stroke care in current and future waves. Messaging should encourage attendance for emergencies and stroke systems should re-examine code stroke protocols to mitigate inefficiencies.

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Abstract TP322: Additional Factors May Affect Hospital Performance Ratings on Ischemic Stroke Care in California

Stroke ◽

10.1161/str.47.suppl_1.tp322 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Limin Wang ◽

Merry Holliday-Hanson ◽

Joseph Parker

Keyword(s):

Ischemic Stroke ◽

Geographic Location ◽

Stroke Care ◽

Hospital Performance ◽

Performance Ratings ◽

Tissue Type ◽

Stroke Severity ◽

Discharge Data ◽

Insurance Type ◽

Hospital Characteristics

Objectives: A report on ischemic stroke care at California hospitals was based on risk-adjusted 30-day mortality and accounted for many important risk factors (patient demography, clinical characteristics, and stroke severity). Other studies have indicated that geographic location, hospital characteristics and insurance type may also be drivers of differences in quality of care. The effect that these and other factors may have on hospital performance ratings for ischemic stroke is not well understood. Methods: Data used were from the California patient discharge data 2011-2013, collected by the Office of Statewide Health Planning and Development (OSHPD). Hospitals were chosen according to their performance in two recent hospital “report cards” on stroke produced by OSHPD. We compared 15 hospitals rated as “Better” with 14 “Worse” hospitals (10615 patients) on patient demographics, geographic location, insurance type, hospital characteristics, tissue-type plasminogen activator (tPA) use and expected 30-day mortality rate. Results: Patients admitted to “Worse” hospitals were more likely to be younger, white or Hispanic, and reside in lower income zip codes than “Better” hospitals ( P <0.001). “Worse” hospitals served a significantly higher percentage of patients with Medi-Cal insurance than “Better” hospitals (14.4% vs 9.6%, P <0.001). There were no significant differences in hospital geography or teaching status, bed size or Get With the Guidelines-Stroke Hospitals status between “Worse” and “Better” hospitals. Patients admitted to “Worse” hospitals had similar lengths of stay as those at “Better” hospitals and the transfer rate was also similar. “Worse” hospitals coded significantly fewer secondary diagnoses compared to “Better” hospitals (40.5% vs 53.0%, P <0.005). The tPA usage rate was significantly higher in the “worse” group than the “Better” group (11.5% vs 9.2%, P <0.005). “Worse” hospitals had significantly lower expected 30-day mortality rates compared to “Better” hospitals (8.8% vs 11.6%, P <0.005). Conclusion: Hospital performance ratings on ischemic stroke outcome were significantly associated with patient geographic location, socioeconomic status, and insurance type, but were not related to hospital characteristics.

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Trends in the seeking of emergency service for ischemic stroke and its risk factors during the COVID-19 pandemic, a study from Taiwan

Neurology Asia ◽

10.54029/2021axy ◽

2021 ◽

Vol 26 (3) ◽

pp. 441-447

Author(s):

Yi Te Tsai ◽

Yachung Jeng ◽

Hsiu-Hsi Chen ◽

Kai-Chieh Chang

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Emergency Services ◽

Stroke Care ◽

University Hospital ◽

Minor Stroke ◽

Stroke Severity ◽

Health Seeking ◽

Stroke Patients ◽

Ich Score

Background & Objectives: COVID-19 may influence the health seeking behavior of acute ischemic stroke patients. This study aimed to determine the characteristics of the patients who visited the emergency room in a centre designated for stroke care in Taiwan. Methods: This was a retrospective database-based study comparing the severity of ischemic stroke, intracerebral hemorrhage (ICH), and risk factors of patients seen between 2019 and 2020 in the National Taiwan University Hospital Yunlin Branch. Patients with or without thrombolysis therapy were analysed. Results: The median NIHSS of ischemic stroke patients were lower in 2019 than in 2020 (p = 0.015). The difference was seen in non-thrombolysis patients (2019: 3[1-6] vs. 4 [2-7.5], p = 0.012) but not in thrombolysis patients. The frequency of minor stroke was higher in 2019 (45.1%) than in 2020 (37.9%, p = 0.038). The discharge mRS was lower overall (p = 0.004) and in non-thrombolysis patients (0.003), but not in thrombolysis patients in 2019. As for the ICH patients, the severity of ICH score (p = 0.021) and discharge mRS (p = 0.001) were also lower in 2019. The frequencies of risk factors of stroke were higher in 2019 than in 2020, including smoking (24% vs. 18.2%, p = 0.046), alcohol (11.9% vs. 7.5%, p = 0.039), hypertension (72.9% vs. 66.2%, p = 0.039), history of stroke (16.5% vs. 11.6%, p = 0.047), and atrial fibrillation (11.9% vs. 7.5%, p = 0.039). Conclusions: This study in Taiwan revealed a decline in the willingness to seek emergency services under the influence of COVID-19 among patients with lower stroke severity, especially those with more risk factors.

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Stroke severity predicts transportation time and time until recanalization therapy in acute strokes

10.21203/rs.2.9586/v1 ◽

2019 ◽

Author(s):

Stefan Mausbach ◽

Martin Jünemann ◽

Tobias Braun ◽

Björn Misselwitz ◽

Manfred Kaps ◽

...

Keyword(s):

Public Awareness ◽

Treatment Options ◽

Stroke Care ◽

Hospital Treatment ◽

Stroke Severity ◽

Severe Stroke ◽

Symptom Recognition ◽

Aging Populations ◽

Icd 10 ◽

Appropriate Therapy

Abstract Background Ischemic stroke has rising prevalence in aging populations. Treatment depends on quick symptom recognition, transport to a hospital with a dedicated stroke care, imaging, and initiation of treatment, if indicated. The aim of this study is to show that transport, imaging, and treatment times depend on the severeness of the stroke, with more severe strokes being favored. Methods Statistical analysis was performed with data from a registry for quality assurance in stroke care in Hesse, Germany. Data was analyzed regarding ICD-10, and patients with I63 were further investigated. Patients with NIHSS ≥ 4 were included and subdivided into 4 ≤ NIHSS ≤ 11 (moderate stroke) and NIHSS ≥ 12 (severe stroke). Transport to hospital, time to image, and time to treatment were analyzed. Results Patients with severe strokes reach the hospital faster and in higher numbers in comparison to moderate strokes. If appropriate therapy is applied, in-hospital treatment regarding imaging is similar in both groups. Thrombolysis or endovascular treatment is initiated faster for severe strokes. Conclusion More public awareness of strokes is needed, specifically for moderate strokes to reach faster transport times to hospital as well as modern treatment options up to 24 hours for eligible patients. Individual standards need to be applied in each stroke treating hospital to guarantee the same fast treatment times for moderate and severe strokes.

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A study of age as a risk factor in ischemic stroke of elderly

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20191634 ◽

2019 ◽

Vol 7 (5) ◽

pp. 1553

Author(s):

Hari Priya Reddy ◽

Jaganath A. ◽

Nagaraj N. ◽

Visweswara Reddy Y. J.

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Ischemic Stroke ◽

Stroke Care ◽

Neurological Deficits ◽

Stroke Severity ◽

Age Group ◽

Severe Stroke ◽

Specific Factors ◽

Successful Prevention

Background: The aim of the study was to determine the effect of age as a risk factor and a determinant of outcome in elderly ischemic stroke patients.Methods: This is an observational study. One hundred, successive elderly patients aged 60 years and above, admitted with acute ischemic stroke in PESIMSR over a period of 18 months were prospectively studied. Patients with hemorrhagic stroke, neurological deficits following trauma or following infection were excluded. Demographics, risk factors, stroke severity at admission were estimated by NIHSS. Risk factors and clinical profile were noted and compared among male and female patients. Outcome at discharge was measured by-mRS-modified ranking score.Results: Patients in age group 60-75 years presented with less severe stroke and better mRS when compared to >75 years age group. Complications were significantly higher among the older age group.Conclusions: The risk factors identified for ischemic stroke in the present study are diabetes, hypertension, dyslipidaemia, obesity, smoking, and alcohol. Severity of stroke at presentation, clinical outcome and complication rate during the in-hospital stay were all significantly affected by the age, more so in ischemic stroke. Age specific factors of stroke prevention are crucial for successful prevention and implementation of well-organized stroke care.

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Access to Mechanical Thrombectomy for Ischemic Stroke in the United States

Stroke ◽

10.1161/strokeaha.120.033485 ◽

2021 ◽

Author(s):

Hooman Kamel ◽

Neal S. Parikh ◽

Abhinaba Chatterjee ◽

Luke K. Kim ◽

Jeffrey L. Saver ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

The United States ◽

Sensitivity Analyses ◽

Stroke Severity ◽

Discharge Data ◽

Cerebral Vessel

Background and Purpose: Mechanical thrombectomy helps prevent disability in patients with acute ischemic stroke involving occlusion of a large cerebral vessel. Thrombectomy requires procedural expertise and not all hospitals have the staff to perform this intervention. Few population-wide data exist regarding access to mechanical thrombectomy. Methods: We examined access to thrombectomy for ischemic stroke using discharge data from calendar years 2016 to 2018 from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Facilities were classified as hubs if they performed mechanical thrombectomy, gateways if they transferred patients who ultimately underwent mechanical thrombectomy, and gaps otherwise. We used standard descriptive statistics and unadjusted logistic regression models in our primary analyses. Results: Among 205 681 patients with ischemic stroke, 100 139 (48.7% [95% CI, 48.5%–48.9%]) initially received care at a thrombectomy hub, 72 534 (35.3% [95% CI, 35.1%–35.5%]) at a thrombectomy gateway, and 33 008 (16.0% [95% CI, 15.9%–16.2%]) at a thrombectomy gap. Patients who initially received care at thrombectomy gateways were substantially less likely to ultimately undergo thrombectomy than patients who initially received care at thrombectomy hubs (odds ratio, 0.27 [95% CI, 0.25–0.28]). Rural patients had particularly limited access: 27.7% (95% CI, 26.9%–28.6%) of such patients initially received care at hubs versus 69.5% (95% CI, 69.1%–69.9%) of urban patients. For 93.8% (95% CI, 93.6%–94.0%) of patients with stroke at gateways, their initial facility was capable of delivering intravenous thrombolysis, compared with 76.3% (95% CI, 75.8%–76.7%) of patients at gaps. Our findings were unchanged in models adjusted for demographics and comorbidities and persisted across multiple sensitivity analyses, including analyses adjusting for estimated stroke severity. Conclusions: We found that a substantial proportion of patients with ischemic stroke across the United States lacked access to thrombectomy even after accounting for interhospital transfers. US systems of stroke care require further development to optimize thrombectomy access.

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Abstract MP22: Sex Differences in the Delivery of Acute Telestroke Care

Stroke ◽

10.1161/str.52.suppl_1.mp22 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Johanna L Morton ◽

Suraj Didwania ◽

Eric Anderson ◽

Jason Hallock

Keyword(s):

Sex Differences ◽

Ischemic Stroke ◽

Acute Stroke ◽

Patient Population ◽

Functional Outcomes ◽

Stroke Care ◽

Stroke Severity ◽

Acute Stroke Care ◽

Presenting Symptoms ◽

Suspected Stroke

Background: Sex differences are encountered in many aspects of ischemic stroke, including risk factors, presenting symptoms, stroke mechanism, acute interventions and functional outcomes. As telestroke services continue to expand, many patients utilize telestroke for the evaluation and treatment of suspected stroke symptoms. To date, the existence of such differences between sexes has not been identified in the patient population having utilized telestroke for acute stroke care. Methods: A retrospective observational study of the experience of a single teleneurology practice serving 340 hospitals from April 2018 to June 2020 was performed. Patients seen in the emergency department (ED) with a diagnosis of suspected stroke were included. Data from the acute stroke encounter was reported through the current medical record platform. Results: Within the queried period, there were 11,454 male and 11,794 female patients identified as having received ED telestroke evaluation for suspected acute stroke. Males were younger than females (67 vs 70, P <0.01). Males had higher rates of prior stroke, hypertension, diabetes, hyperlipidemia, and coronary disease than females ( P <0.01), while females had higher rates of atrial fibrillation ( P =0.03) and TIA ( P <0.01). Rates of antiplatelet and anticoagulants were higher in males ( P <0.01) than females. There were no differences in time to ED presentation, time to request consult or make a thrombolysis decision, or length of consult. Females had higher stroke severity ( P <0.01) and door-to-needle times ( P <0.01), but lower alteplase rates ( P =0.02) compared to males. Conclusion: This review of a national heterogeneous telestroke patient population is indicative of sex differences in multiple aspects of acute ischemic stroke, most notably in thrombolysis delivered via telestroke. Further investigation into the etiology of such differences is warranted, as well as a survey of functional outcomes. As telemedicine continues to expand in the era of the COVID-19 pandemic, it is imperative that the reasons behind this disparity are investigated.

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Mobile Stroke Units: Current and Future Impact on Stroke Care

Seminars in Neurology ◽

10.1055/s-0040-1722724 ◽

2021 ◽

Vol 41 (01) ◽

pp. 009-015

Author(s):

Ritvij Bowry ◽

James C. Grotta

Keyword(s):

Ischemic Stroke ◽

Clinical Outcomes ◽

Stroke Care ◽

The United States ◽

Hospital Treatment ◽

Additional Time ◽

Stroke Units ◽

Require Time ◽

Intravenous Tissue Plasminogen Activator ◽

Telemedicine Technology

AbstractIschemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.

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Abstract TP160: Degree of Functional Independence After an Ischemic Stroke Affects Quality of Life Similarly in Men and Women

Stroke ◽

10.1161/str.47.suppl_1.tp160 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Stacie L Demel ◽

Jane Khoury ◽

Charles J Moomaw ◽

Heidi Sucharew ◽

Kathleen Alwell ◽

...

Keyword(s):

Quality Of Life ◽

Ischemic Stroke ◽

Functional Outcome ◽

Retrospective Chart Review ◽

Functional Independence ◽

Stroke Severity ◽

Men And Women ◽

Related Data ◽

Proxy Responses

Background: Women have worse quality of life (QoL) after an ischemic stroke (IS) compared with men for unclear reasons. We hypothesized that men and women may value functional independence differently. We assessed the association between sex, functional outcome, and quality of life within a large prospective cohort of ischemic stroke patients. Methods: Within the Greater Cincinnati/Northern Kentucky catchment area of 1.3 million we prospectively screened local hospital stroke admission diagnoses in 2005 and 2010. A subset of physician-confirmed IS patients were interviewed at baseline and followed longitudinally. Medical history and stroke-related data were collected through standardized retrospective chart review. Pre-stroke and 3-month modified Rankin Scale (mRS) was assessed, and European Quality of Life (EQ-5D) was administered at 3 months. Multiple regression analysis was used to compare QoL between men and women across mRS categories, adjusted for age, race, baseline mRS, stroke severity history of depression, diabetes, and use of proxy responses. Results: The GCNK follow-up cohorts from 2005 and 2010 included 964 adult IS patients, of which 797 were interviewed at 3 months post stroke. Women comprised 50% of the cohort and were older than men on average (68.4 ± 14.2 vs. 65.2 ± 13, p<.001) years at the time of their stroke. Women had worse functional outcomes (median mRS 3 vs. 2, p=.02) and quality of life (EQ-5D 0.55 vs. 0.65, p=.03), even after adjustment for the covariates listed above. The EQ-5D index was no different in men and women for each point on the mRS spectrum (i.e., there was no interaction between sex and 3-month mRS; Figure). Conclusion: In this cohort study, we confirmed worse functional outcome and worse quality of life in women after stroke. However, at each level on the mRS spectrum, men and women valued their quality of life similarly. Further research is needed on the reasons for worse outcomes in women than men.

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Endovascular therapy for ischemic stroke

Neurology ◽

10.1212/wnl.0000000000003981 ◽

2017 ◽

Vol 88 (22) ◽

pp. 2123-2127 ◽

Cited By ~ 51

Author(s):

Atte Meretoja ◽

Mahsa Keshtkaran ◽

Turgut Tatlisumak ◽

Geoffrey A. Donnan ◽

Leonid Churilov

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Treatment Time ◽

Prediction Interval ◽

Stroke Severity ◽

Vessel Occlusion ◽

Treatment Delays ◽

Mr Clean

Objective:To quantify the patient lifetime benefits gained from reduced delays in endovascular therapy for acute ischemic stroke.Methods:We used observational prospective data of consecutive stroke patients treated with IV thrombolysis in Helsinki (1998–2014; n = 2,474) to describe distributions of age, sex, stroke severity, onset-to-treatment times, and 3-month modified Rankin Scale (mRS) in routine clinical practice. We used treatment effects by time of endovascular therapy in large vessel occlusion over and above thrombolysis as reported by the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) study to model the shift in 3-month mRS distributions with reducing treatment delays. From the 3-month outcomes we derived patient-expected lifetimes and cumulative long-term disability with incremental treatment delay reductions.Results:Each minute saved in onset-to-treatment time granted on average 4.2 days of extra healthy life, with a 95% prediction interval 2.3–5.4. Women gained slightly more than men due to their longer life expectancies. Patients younger than 55 years with severe strokes of NIH Stroke Scale score above 10 gained more than a week per each minute saved. In the whole cohort, every 20 minutes decrease in treatment delays led to a gain of average equivalent of 3 months of disability-free life.Conclusions:Small reductions in endovascular delays lead to marked health benefits over patients' lifetimes. Services need to be optimized to reduce delays to endovascular therapy.

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