Abstract TMP71: Increasing Prevalence of Secondary Intracerebral Hemorrhage in Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Fadar O Otite ◽  
Anita Tipirneni ◽  
Priyank Khandelwal ◽  
Amer M Malik ◽  
Kristine O’phelan
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Acute Ischemic Stroke ◽  
Nationwide Inpatient Sample ◽  
Intravenous Thrombolysis ◽  
The United States ◽  
Primary Diagnosis ◽  
Temporal Data ◽  
Innovative Strategies ◽  
Hospital Morbidity

Background: Temporal data on secondary intracerebral hemorrhage (SICH) risk in acute ischemic stroke (AIS) patients (pts) is sparse since implementation of current measures to lessen times to intravenous thrombolysis (tPA) and/or endovascular reperfusion. Aims: (1) Evaluate trends in SICH prevalence in AIS pts in the United States from 2004-2013 and to compare SICH risk following tPA and mechanical thrombectomy (MT) from 2011-2013 to risk in earlier periods. (2) Assess the magnitude of the current association of SICH with in-hospital morbidities and mortality in AIS. Methods: All adults with a primary diagnosis of AIS (n=4,355,140) were identified from the 2004-2013 Nationwide Inpatient Sample. We computed weighted risk of SICH in AIS according to age, sex and intervention received (tPA, MT or no-intervention). Multivariate models were used to compare SICH risks in the period 2004-2007 to periods 2008-2010 and 2011-2013, respectively, and to evaluate association of SICH with in-hospital morbidity, mortality, length-of-stay (LOS) and cost. Results: SICH risk increased over the study period but most of the increase occurred after 2010 (figure 1). From the period 2004-2007 to period 2011-2013, SICH risk increased by 75% in IV tPA pts (4.8%-8.4%), 164% in MT pts (8.1%-21.4%) and by 367.8% in no-intervention pts (0.5%-2.3%). Risks increased with age but only in tPA pts and did not vary by sex in both tPA and MT pts after multivariate adjustment. SICH was associated with >200% increased odds of ventilator use, pneumonia, sepsis, acute renal failure, deep venous thrombosis, pulmonary embolism and 67% reduced odds of home disposition compared to non-SICH. Mortality in SICH decreased from 26% to 18.3% compared to 6.1% to 4.0% in the non-SICH patients over the entire period. SICH was associated with >$8,000 increase in cost and >3-day increase in mean LOS. Conclusion: The burden of SICH in AIS is growing. Innovative strategies are needed to prevent SICH and/or alleviate its sequelae.

Abstract P872: Persistent Inequities in Intravenous Thrombolysis for Acute Ischemic Stroke in the United States: Results From the Nationwide Inpatient Sample

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Philip Y Sun ◽  
Ling Zheng ◽  
Michelle P Lin ◽  
Steven Cen ◽  
Nerses Sanossian ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Nationwide Inpatient Sample ◽  
Intravenous Thrombolysis ◽  
The United States ◽  
Stroke Survivors ◽  
Very Elderly ◽  
Pronounced Increase ◽  
Race Ethnicity ◽  
To Receive

Background: Intravenous thrombolysis (IVT) was approved for acute ischemic stroke (AIS) 25 yrs ago, yet few AIS patients receive it, with inequities by race/ethnicity, sex, and geography. With expanding evidence-based programs, we hypothesized increases in IVT utilization and reduction in inequities. Methods: Using the Nationwide Inpatient Sample (NIS), we assessed temporal trends from 2002 to 2015 in IVT for AIS (weighted N=6,694,081) by sex, race/ethnicity, age, insurance, and hospital location/teaching status strata using survey - weighted logistic regression. Covariates included socio-demographics, comorbidities, and hospital characteristics. We calculated odds ratios for IVT by each category in 2002-2008 and 2009-2015. Results: IVT for AIS increased from 1.0% in 2002 to 6.8% in 2015, with an overall adjusted annual relative ratio (AARR) of 1.15 (CI 1.14-1.16). Individuals 18-44 yrs had the highest rate of IVT in 2015. The very elderly (≥85 yrs) had the most pronounced increase in IVT (AARR 1.18, CI 1.17-1.19). The sex disparity in IVT improved, but in 2009-2015, women were still 6% less likely to receive IVT than men (Fig 1). Individuals 18-44 yrs were ~3-fold more likely to receive IVT than the very elderly. IVT inequities for black and Hispanic stroke survivors lessened, but blacks remained ~20% less likely than whites to receive IVT. Government-insured patients were ~25% less likely to receive IVT compared to privately insured. Urban AIS patients were up to 4-fold more likely to receive IVT than rural dwellers. Conclusion: From 2002 through 2015, IVT for AIS in the U.S. increased regardless of race/ethnicity, sex, and age among ≥18 yrs, with the most pronounced increase among the very elderly. Despite encouraging trends, only 1 in 15 AIS patients received IVT and persistent inequities remain for blacks, women, government-insured, and rural stroke survivors, highlighting the need for intensifying stroke literacy and preparedness and enhancing systems of care.

Abstract P12: Alteplase Reduces Mortality in Patients With Ischemic Stroke and Atrial Fibrillation: Analysis of the IAC Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shadi Yaghi ◽  
Eva Mistry ◽  
Adam H De Havenon ◽  
Christopher Leon Guerrero ◽  
Amre Nouh ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Infarct Volume ◽  
Intravenous Thrombolysis ◽  
The United States ◽  
Hemorrhagic Transformation ◽  
Stroke Patients ◽  
Increased Risk ◽  
Significant Difference

Background and Purpose: Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke. Methods: We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders. Results: In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p <0.001) but overall reduced risk of 90-day mortality (adjusted OR 0.58, 95% CI 0.39 - 0.87, p = 0.009). Among patients undergoing MT, alteplase use was associated with a trend towards a reduction in 90-day mortality (adjusted OR 0.68 95% CI 0.45 - 1.04, p = 0.077). In the subgroup of patients prescribed DOAC treatment (n = 327; 24 received alteplase), alteplase treatment was associated with a trend towards smaller infarct size (< 10 mL), (adjusted OR 0.40, 95% CI 0.15 - 1.12, p = 0.082) without a significant difference in the odds of 90-day mortality (adjusted OR 0.51, 95% CI 0.12 - 2.13, p = 0.357) or hemorrhagic transformation (adjusted OR 0.27, 95% CI 0.03 - 2.07, p = 0.206). Conclusion: Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.

Abstract MP25: Inequities in Interhospital Transfer for Acute Ischemic Stroke in the United States: Lower Odds for Women and the Underinsured

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Daniel M Oh ◽  
Daniela Markovic ◽  
Amytis Towfighi
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Multinomial Logistic Regression ◽  
Private Insurance ◽  
Stroke Care ◽  
The United States ◽  
Primary Diagnosis ◽  
Multinomial Logistic Model ◽  
Lower Odds ◽  
Interhospital Transfer

Background: Patients with acute ischemic stroke (AIS) may undergo interhospital transfer (IHT) for higher level of care. Although the Emergency Medical Treatment and Active Labor Act stipulates that patients should be transferred to and accepted by referral hospitals if indicated, it offers few concrete guidelines, making it vulnerable to bias. We hypothesized that (1) IHT for AIS has increased over recent years and (2) minorities, women, and those without insurance had lower odds of IHT. Methods: Using the National Inpatient Sample, adults (>18 yrs) with a primary diagnosis of AIS from 2010 to 2017 (n=770,970) were identified, corresponding to a weighted sample size of 3,798,440. Those transferred to another acute hospital were labeled IHT. Yearly rates of IHT were assessed. Adjusted odds ratio (AOR) of IHT (vs. not transferred) were compared in 2014-2017 vs. 2010-2013 using a multinomial logistic model, adjusting for socioeconomic, medical, and hospital characteristics. Multinomial logistic regression was used to determine odds of IHT by race/ethnicity, sex, and insurance status, adjusting for the above characteristics. Results: From 2010 to 2017, the proportion of IHT declined from 3.2% (SE 0.2) to 2.9% (SE 0.1). Comparing IHT in 2014-2017 to 2010-2013 showed lower odds of IHT (OR 0.93, 95% CI 0.88-0.99), but this difference did not remain significant in the fully adjusted model. Fully adjusted OR showed that black patients were more likely than white patients to undergo IHT (AOR 1.13, 1.07-1.20). Women were less likely than men to be transferred (AOR 0.89, 0.86-0.92). Compared to those with private insurance, those with Medicaid (AOR 0.86, 0.80-0.91), self-pay (0.64, 0.59-0.70), and no charge (0.64, 0.46-0.88) were less likely to undergo IHT. Conclusions: Adjusted odds of IHT for AIS did not change significantly. Blacks were more likely than whites to be transferred; however, women and the uninsured/underinsured were less likely to be transferred. Further studies are needed to further understand these inequities and develop interventions and policies to ensure that all individuals have equitable access to stroke care, regardless of their race, sex, or ability to pay.

Abstract WP41: Age-Specific Differences in the Use of Endovascular Treatment and Hospital Outcomes in Patients With Acute Ischemic Stroke: A Community-Wide Perspective

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Saqib A Chaudhry ◽  
Iqra N Akhtar ◽  
Ameer E Hassan ◽  
Mohammad Rauf A Chaudhry ◽  
Mohsain Gill ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
International Classification Of Diseases ◽  
The United States ◽  
Primary Diagnosis ◽  
Limited Information ◽  
Hospital Outcomes ◽  
The Impact ◽  
Over Time

Background: Relatively limited information is available about trends over time in the use of endovascular treatment in patients of different ages hospitalized with acute ischemic stroke and the association between use of thrombectomy treatment and hospital outcomes in age strata. We performed this analysis to evaluate trends in the utilization of endovascular treatment in acute ischemic stroke by age strata in real-world practice. Methods: We conducted this study by identifying patients admitted with a primary diagnosis of ischemic stroke in the United States from 2007 to 2016 using the Nationwide Inpatient Sample. International Classification of Diseases, ninth revision, and tenth, Clinical Modification (ICD-9-CM, ICD-10-CM) codes were used to identify patients admitted for ischemic stroke and undergoing endovascular treatment. Results: Of the 4,590,533 patients admitted with ischemic stroke, 269,922 (5.88%) received intravenous thrombolytic treatment, and 51,375 (1.12%) underwent endovascular treatment. There is almost 12-fold significant increase in the use of endovascular treatment patients admitted with acute ischemic stroke between 2007 to 2016. Patients who were 75 years and older experienced a marked increase in the receipt of endovascular treatment over time (0.12% 2007; 1.91% 2016; trend p<0.0001). We observed statistically significant improvement in outcomes including minimal disability (6.3% to 18.8%; trend p<0.0001) and in hospital mortality (25.0% to 16.5%; trend p<0.0001) in patients 75 years and older treated with endovascular treatment in study period. We observed similar trend of outcomes in each of the other age-specific groups under study (<55, 55-64 and 65-74 years). Conclusions: Our findings indicate a recent increase in the use of endovascular in middle-aged and elderly patients with acute ischemic strokes. The impact of endovascular treatment on hospital outcomes was observed in each of our age strata understudy though the magnitude of absolute and relative benefit varied according to age.

Abstract P76: Effect of Covid-19 Pandemic on Acute Ischemic Stroke Hospitalizations Among Medicare Beneficiaries in the United States

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Quanhe Yang ◽  
Xin Tong ◽  
Sallyann Coleman King ◽  
Robert K Merritt
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
The United States ◽  
Primary Diagnosis ◽  
Emergency Department Visits ◽  
Fee For Service ◽  
Long Term Effects ◽  
Percent Reduction ◽  
Race Ethnicity

Introduction: Emergency department visits and hospitalizations for acute ischemic stroke (AIS) declined significantly following the declaration of COVID-19 as a national emergency on March 13, 2020 in the United States. No study has examined the volume and nature of AIS hospitalizations among older adults in the U.S. amidst the COVID-19 pandemic. This study examined the trend and compared the characteristics of Medicare fee-for-service (FFS) beneficiaries ≥65 years hospitalized with a primary AIS diagnosis in the same timeframe before and after the COVID-19 pandemic. Methods: We included hospitalizations with a primary diagnosis of AIS (ICD-10 I63) among Medicare FFS beneficiaries from week 11 to 24 in 2019 and 2020. We estimated the percent reduction of AIS hospitalizations between 2019 and 2020 by age, sex, race/ethnicity, and state. We tested for difference in distribution by age group, sex and race/ethnicity between 2019 and 2020 based on χ 2 test. Results: During the 14-weeks from March 8 to June 13, 2020, AIS hospitalizations among FFS beneficiaries were reduced by 23.7% compared to weeks 11 to 24 in 2019 (March 10 to June 15) (49,607 in 2019 vs. 37,860 in 2020). A greater percent reduction in AIS hospitalizations was observed with older age (27.2% among ≥85 years vs. 20.6% among persons 65-74 years, p<0.001). The magnitude of reduction was similar between men (23.8%) and women (23.6%, p=0.791), and among non-Hispanic white (24.2%), non-Hispanic black (22.4%), Hispanic (19.3%), and other (22.4%, p=0.189). AIS hospitalization trends varied by state ranging from 1.6% in New Hampshire to 39.8% in Montana. Conclusion: Hospitalizations with a primary AIS diagnosis among Medicare FFS beneficiaries were reduced by 24% during weeks 11 to 24 of the COVID-19 pandemic compared to the previous year in the United States. AIS hospitalization reductions varied substantially by state. Further study is needed to examine the long-term effects of COVID-19 pandemic on stroke outcomes.

Diagnostic Yield of Electroencephalography When Seizure Is Suspected in Acute Ischemic Stroke

2021 ◽  
pp. 194187442110212
Author(s):  
Mohanad AlGaeed ◽  
Manjot Grewal ◽  
Prarthana Hareesh ◽  
Soha Sadeghikhah ◽  
Hai Chen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Diagnostic Yield ◽  
Care Center ◽  
Tertiary Care ◽  
Secondary Analysis ◽  
Retrospective Chart Review ◽  
The United States ◽  
Primary Diagnosis ◽  
Eeg Monitoring

Introduction: Seizures are a common complication after an ischemic stroke. Electroencephalography can assist with the diagnosis of seizures however, the diagnostic yield of its use when seizure is suspected in the setting of acute ischemic stroke is unknown. We aim to evaluate the yield and cost of EEG in the acute ischemic stroke setting. Methods: We conducted a retrospective chart review of patients admitted to a single academic tertiary care center in the United States between September 1, 2015 to November 30, 2019 with a primary diagnosis of acute ischemic stroke and who were monitored on electroencephalography (EEG) for suspected seizures (total number of 70 patients). The primary outcome was how often EEG monitoring changed clinical management defined as starting, stopping, or changing the dose of an anti-epileptic drug. Secondary analysis was estimating the cost of EEG monitoring per change in management. Results: We identified 126 patients admitted with acute ischemic stroke who underwent EEG of which 70 met all inclusion and exclusion criteria. EEG monitoring resulted in a change in management in 22 patients (31%). Predictors associated with EEG monitoring resulting in a change in management were admission to the ICU, pre-existing atrial fibrillation, and symptomatic hemorrhagic transformation. Estimated cost of EEG per change in management was $1374.96 USD. Conclusion: EEG monitoring resulted in a changed management in nearly one-third of patients admitted with acute ischemic stroke suspected of having seizures.

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