Abstract WP46: Patient Characteristics, Quality and Outcomes After Endovascular Therapy for In-Hospital Ischemic Stroke

Introduction: A significant number of acute ischemic strokes occur while patients are hospitalized for other reasons. No national data have been reported on endovascular therapy (EVT) for in-hospital onset stroke. Here we compare the patient characteristics, process measures of quality, and outcomes for in-hospital onset vs. community-onset of strokes in a large US national registry. Methods: We performed a retrospective cohort study of Get With The Guidelines-Stroke (GTWG-Stroke) from January 2008 to June 2018 from 2,333 participating sites that included 2,428,178 patients with acute ischemic stroke. Among 67,493 in-hospital onset strokes, 2494 (3.7%) underwent EVT. We examined the association between key patient characteristics (in-hospital onset, demographics, comorbidities, treatment with EVT) and functional outcomes using multivariable logistic regression models. Results: The rate of EVT increased from 2.5% in 2008 to 6.4% in 2018 (p<0.001), with a significant and sustained increase in EVT after the second quarter of 2015 (p<0.0001). Compared with patients with community-onset strokes, patients with in-hospital onset stroke had longer times to cranial imaging and arterial puncture but similar median NIHSS (16 (9 - 21) vs. 16 (10 - 21) Std Diff 1.9). Patients with in-hospital onset stroke were less likely to undergo EVT within 120 mins of symptom recognition, have symptomatic intracranial hemorrhage, or ambulate independently at discharge. They were more likely to die or be discharged to hospice. Conclusions: Though use of EVT in GWTG-Stroke for in-hospital stroke remains low, it more than doubled in the past decade. Compared with community onset stroke, these patients have longer intervals to CT and arterial puncture, with associated worse functional outcomes. While there may be important differences in baseline patient characteristics between the groups, efforts must still be made to shorten time to reperfusion for in-hospital strokes.

Download Full-text

Abstract 103: Intravenous Thrombolysis for In-Hospital Ischemic Stroke in the Endovascular Era: Findings From the National Get With the Guidelines-Stroke Registry

Stroke ◽

10.1161/str.51.suppl_1.103 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Feras Akbik ◽

Haolin Xu ◽

Ying Xian ◽

Shreyansh Shah ◽

Eric E Smith ◽

...

Keyword(s):

Ischemic Stroke ◽

Temporal Trends ◽

Significant Proportion ◽

Intravenous Thrombolysis ◽

Patient Characteristics ◽

National Registry ◽

Process Measures ◽

Get With The Guidelines ◽

Community Onset ◽

Iv Tpa

Introduction: A significant proportion of acute ischemic strokes occur while patients are hospitalized for other reasons. Limited data exist on the utilization of intravenous alteplase (IV tPA) for in-hospital stroke, particularly in the endovascular era. We compared temporal trends of IV tPA use, patient characteristics, process measures of quality, and outcomes for in-hospital versus community onset strokes in a national registry. Methods: We performed a retrospective cohort study of Get With The Guidelines-Stroke (GTWG-Stroke) from January 2008 to June 2018 from 2,333 participating sites that included 2,428,178 patients with acute ischemic stroke. In-hospital onset was reported in 67,493 patients. We examined the association between stroke onset location, patient characteristics, comorbidities, treatment with IV tPA and unadjusted and adjusted functional outcomes (Table, standardized differences >10% for significance). Results: Of 67,493 patients with in-hospital onset stroke, 11,123 received IV tPA. The rate of IV tPA administration steadily increased, from 9.5% in 2008 to 20.7% in 2017 (p<0.001). Compared with patients with community-onset strokes who were treated with IV tPA, patients with in-hospital onset stroke had longer times to cranial imaging and administration of IV tPA. Patients with in-hospital onset stroke were less likely to be treated within 60 minutes of recognition, and at discharge, ambulate independently or go directly home. They were more likely to die or be discharged to hospice after adjusting for patient and hospital characteristics. Conclusions: In this national cohort, in-hospital onset strokes are increasingly treated with intravenous tPA in a period that spans the endovascular era. Compared with community-onset stroke, patients with in-hospital onset stroke had longer intervals to thrombolysis and worse outcomes. These data highlight opportunities to improve inpatient systems of stroke care further.

Download Full-text

Abstract 203: Use of Endovascular Therapy and Trends in Clinical Outcomes within the Nationwide Get With The Guidelines-Stroke Registry

Stroke ◽

10.1161/str.46.suppl_1.203 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Bijoy K Menon ◽

Jeffrey L Saver ◽

Mayank Goyal ◽

Raul Noguiera ◽

Shyam Prabhakaran ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcomes ◽

Endovascular Therapy ◽

Patient Characteristics ◽

National Registry ◽

Stroke Registry ◽

Large Size ◽

Symptomatic Intracranial Hemorrhage ◽

Independent Ambulation ◽

Get With The Guidelines

Purpose: To determine hospital and patient level characteristics associated with use of endovascular therapy for acute ischemic stroke and to analyze trends in clinical outcome. Methods: Data were from Get With The Guidelines-Stroke hospitals from 4/1/2003 to 6/30/2013. We looked at secular trends in number of hospitals providing endovascular therapy, use of endovascular therapy in these hospitals, and clinical outcomes. We also analyzed hospital and patient characteristics associated with endovascular therapy utilization. Results: Of 1087 hospitals, 454 provided endovascular therapy to at least one patient in the study period. From 2003 to 2012, the proportion of hospitals providing endovascular therapy increased by 1.6%/year (from 12.9% to 28.9%), with a modest drop in 2013 to 23.4%. Use in these hospitals increased from 0.7% to 2% of all ischemic stroke patients (p<0.001) with a modest drop in 2013 to 1.9%. In multivariable analyses, patient outcomes after endovascular therapy improved over time, with reductions in in-hospital mortality (29.6% in 2004 to 16.2% in 2013; p=0.002); and from late 2010, reduction in symptomatic intracranial hemorrhage (ICH) (11% in 2010 to 5% in 2013; p<0.0001) and increased independent ambulation at discharge (24.5% in 2010 to 33% in 2013; p<0.0001) and discharge home (17.7% in 2010 to 26.1% in 2013; p<0.0001) (Attached figure). Hospital characteristics associated with endovascular therapy use included large size, teaching status and urban location while patient characteristics included younger age, EMS transport, absence of prior stroke and white race. Conclusion: Use of endovascular therapy increased modestly in this national registry from 2003 to 2012 and decreased in 2013. Clinical outcomes improved notably from 2010 to 2013, coincident with the introduction of newer thrombectomy devices.

Download Full-text

E-055 Patient characteristics, quality and outcomes after endovascular therapy for in-hospital ischemic stroke

10.1136/neurintsurg-2020-snis.91 ◽

2020 ◽

Author(s):

F Akbik ◽

H Xu ◽

Y Xian ◽

S Shah ◽

E Smith ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Therapy ◽

Patient Characteristics ◽

Quality And Outcomes

Download Full-text

An older thrombus delays reperfusion after mechanical thrombectomy for ischemic stroke

Thrombosis and Haemostasis ◽

10.1055/a-1522-4507 ◽

2021 ◽

Author(s):

Takaya Kitano ◽

Yumiko Hori ◽

Shuhei Okazaki ◽

Yuki Shimada ◽

Takanori Iwamoto ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcomes ◽

Endovascular Procedures ◽

Mechanical Thrombectomy ◽

Patient Characteristics ◽

Reperfusion Therapy ◽

Neutrophil Extracellular Trap ◽

Time Analysis ◽

Restricted Mean Survival Time ◽

Quality And Outcomes

Background: Thrombosis is a dynamic process, and a thrombus undergoes physical and biochemical changes that may alter its response to reperfusion therapy. This study assessed whether thrombus age influenced reperfusion quality and outcomes after mechanical thrombectomy for cerebral embolism. Methods: We retrospectively evaluated 185 stroke patients and thrombi that were collected during mechanical thrombectomy at three stroke centers. Thrombi were pathologically classified as fresh or older based on their granulocytes’ nuclear morphology and organization. Thrombus components were quantified, and the extent of NETosis (the process of neutrophil extracellular trap formation) was assessed using the density of citrullinated histone H3-positive cells. Baseline patient characteristics, thrombus features, endovascular procedures, and functional outcomes were compared according to thrombus age. Results: Fresh thrombi were acquired from 43 patients, and older thrombi were acquired from 142 patients. Older thrombi had a lower erythrocyte content (P<0.001) and higher extent of NETosis (P=0.006). Restricted mean survival time analysis revealed that older thrombi were associated with longer puncture-to-reperfusion times (difference: 15.6 minutes longer for older thrombi, P=0.002). This association remained significant even after adjustment for erythrocyte content and the extent of NETosis (adjusted difference: 10.8 min, 95% CI: 0.6–21.1 min, P=0.039). Compared with fresh thrombi, older thrombi required more device passes before reperfusion (P<0.001) and were associated with poorer functional outcomes (adjusted common OR: 0.49, 95% CI: 0.24–0.99). Conclusions: An older thrombus delays reperfusion after mechanical thrombectomy for ischemic stroke. Adding therapies targeting thrombus maturation may improve the efficacy of mechanical thrombectomy.

Download Full-text

Abstract WP336: Patient Characteristics and in Hospital Complications Associated With High Cost Ischemic Stroke Admissions

Stroke ◽

10.1161/str.47.suppl_1.wp336 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Khawja A Siddiqui ◽

Xiu Liu ◽

Karen E Lynch ◽

Sadiqa B Mahmood ◽

Hui Zheng ◽

...

Keyword(s):

Ischemic Stroke ◽

Fasting Blood Glucose ◽

Patient Characteristics ◽

Artery Occlusion ◽

Stroke Severity ◽

Administrative Claims ◽

Comfort Care ◽

Logistic Regression Models ◽

Public Health Burden ◽

Targeted Interventions

Introduction: Stroke poses a major public health burden. We sought to determine the clinical and demographic variables associated with high cost among hospitalized ischemic stroke (IS) patients. Methods: Using our local Get with the Guidelines Stroke database, we identified 1,578 IS patients admitted from 2010- 2013 and linked them to administrative claims data (EPSI, inc). Patients in the highest cost quartile (n=394) were compared to all others (n=1184) using descriptive statistics and multilevel logistic regression models. All financial data are relative costs, reported as medians [IQR] multiplied by a constant. Results: The median relative cost in the top quartile was 4 times higher than that for all other patients. In univariate analyses, the groups differed substantially (Table 1). In multivariable models, high cost patients were more likely to have discharge ICD 9 codes of 433.11 or 434.91 (IS patients with carotid or cerebral artery occlusion), higher serum creatinine, fasting blood glucose and NIHSSS. They were more likely to receive IV or IA reperfusion, remain NPO during their stay or develop hospital acquired pneumonia, and less likely to transition to comfort care. The C statistic for a model with NIH stroke scale only performed well (c= 0.77) even when compared to a model with all variables present on admission (c= 0.83) or the fully adjusted model (c= 0.86). Conclusion: Many patient level demographic and clinical characteristics available on admission predict high cost, even after adjustment for stroke severity. Cost management opportunities may exist for targeted interventions, perhaps through geographic co-location or specialized stroke units.

Download Full-text

Abstract 145: Transferred Ischemic Stroke Patients Have Worse Outcomes After Endovascular Therapy

Stroke ◽

10.1161/str.45.suppl_1.145 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Malik M Adil ◽

Shyam Prabhakaran

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Hospital Mortality ◽

Endovascular Treatment ◽

Endovascular Therapy ◽

Systems Of Care ◽

Inpatient Rehabilitation ◽

Patient Characteristics ◽

Transferred Patients ◽

Stroke Systems Of Care

Background and Objective: Ischemic stroke (IS) patients may require inter-facility transfer for higher level of care. Endovascular treatment is the main indication for transfer. We aimed to compare patient characteristics and clinical outcomes amongst transferred vs. non-transferred IS patients who undergo endovascular therapy. Methods: Patients admitted to US hospitals between 2008 and 2011 with a primary discharge diagnosis of IS were identified by ICD-9 codes (433, 434, 436 and 437.1). Mechanical embolectomy (ME) was identified using the ICD-9 procedure code 39.74 or DRG 543 and cerebral angiography (CA) day 0-1 by 88.41. Using logistic regression, we estimated the odds ratio (OR) and 95% confidence intervals (CI) for intracerebral hemorrhage (ICH), in-hospital mortality, and good outcomes (discharge home or inpatient rehabilitation) among transfer vs. non-transfers, adjusting for potential confounders. Results: Of 116,382 patients with IS treated with ME or CA (7.0% of all patients with IS), 10.1% were performed in transferred patients. Atrial fibrillation and hyperlipidemia was significantly higher in IS transfers. In-hospital mortality was higher among IS transfers (9.0% vs. 3.7%; p<0.001) and discharge to home or inpatient rehabilitation was less likely among transferred IS patients (70.2% vs. 80.6%; p<0.001). ICH was higher among IS transfers (4.6% vs. 1.7%; p<0.001). After adjusting for age, gender, race, presence of hypertension, dyslipidemia, atrial fibrillation, renal failure, alcohol abuse, insurance status, and hospital teaching status, transferred patients had higher odds of ICH (OR 2.0, 95% CI 1.5-2.8, p<0.001)] and death (OR 2.0, 95% CI 1.6-2.4, p<0.001) and lower odds of discharge to home/rehabilitation (OR 0.5, 95% CI 0.4-0.7, p<0.001) . Conclusion: Endovascular treatment for acute ischemic stroke may be associated with worse outcomes among inter-hospital transfer patients compared to non-transfers. Organized stroke systems of care may need to consider pre-hospital strategies to increase direct referrals to comprehensive stroke centers and inter-hospital strategies to reduce delays to treatment.

Download Full-text

Abstract T P16: Indirect Comparison of Functional Outcomes in Stroke Patients Following Endovascular Versus Best Medical Treatment: Insights From Defuse 2 and Axis 2

Stroke ◽

10.1161/str.46.suppl_1.tp16 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Anke Wouters ◽

Robin Lemmens ◽

Soren Christensen ◽

Guido Wilms ◽

Michael Mlynash ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Endovascular Therapy ◽

Functional Outcomes ◽

Indirect Comparison ◽

Control Group ◽

Stroke Patients ◽

Gm Csf ◽

Good Functional Outcome ◽

Best Medical Treatment

Background: Imaging based selection of acute ischemic stroke patients may improve clinical outcomes after endovascular therapy. DEFUSE 2 was a prospective cohort study of ischemic stroke patients who underwent a baseline MRI scan before endovascular therapy. In DEFUSE 2 reperfusion was associated with increased good functional outcome in patients with the target mismatch (TMM) profile, but not in patients without TMM. AXIS 2 was a randomized, controlled, MRI based trial of IV GM-CSF versus placebo. This study, in which endovascular therapy was not permitted, did not show improved functional outcomes between GM-CSF and placebo. We performed an indirect comparison between the outcomes seen in DEFUSE 2 and a control group from AXIS 2. Methods: Patients from AXIS 2 with a confirmed large vessel occlusion of the MCA or ICA on MR angiography, obtained within 9 hours after symptom onset, were selected as a control-group for patients from DEFUSE 2. The primary endpoint was good functional outcome at day 90 defined as a modified Rankin scale score of 0-2. Reperfusion status could only be assessed in the DEFUSE 2 cohort. We performed a stratified analysis based on the presence of TMM for both studies and reperfusion status in DEFUSE 2. Results: We compared good functional outcome in 102 patients (TMM in n=47, 49%) from AXIS 2 and 98 patients (TMM in n=78, 80%) from DEFUSE 2. After correction for differences in age, NIHSS and DWI volume, rates of good functional outcome were similar, 43% in DEFUSE 2 compared to 30 % in AXIS 2 (OR 0.9, 95%CI 0.5-1.7). In DEFUSE 2 patients with the TMM profile in whom reperfusion was achieved, the rate of good functional outcome was increased compared to TMM patients in AXIS 2, 64% versus 32% (OR 3.2, 95%CI 1.2-8.4). In TMM patients from DEFUSE 2 without reperfusion, the rate of good functional outcome was similar (31%), to the TMM patients in AXIS 2 (OR 1.0, 95%CI 0.4-2.3). No difference in outcomes was observed regardless of reperfusion status when a TMM was not present. Conclusion: This indirect, controlled comparison suggests that endovascular treatment resulting in reperfusion may lead to improved outcomes in patients with the TMM profile.

Download Full-text

Abstract WP411: Evaluation of Strategies to Reduce Time to Revascularization in Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.wp411 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Abbigayle M Doerr ◽

Janet Davis ◽

Sheryl Jenkins

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Process Improvement ◽

Stroke Patient ◽

Endovascular Therapy ◽

Functional Outcomes ◽

Primary Outcome ◽

Outcome Analysis ◽

Ischemic Stroke Patient ◽

Acute Ischemic Stroke Patient

Background: There is growing support for the need for process improvement surrounding treatment of acute ischemic stroke, specifically, reducing time to reperfusion in endovascular therapy (EVT). Streamlining protocols from patient presentation to revascularization can lead to improved timelines to treatment and functional outcomes. Purpose: The purpose of this study was to identify the impact on specific hospital based process improvement strategies in the acute ischemic stroke patient population undergoing endovascular therapy with specific intent to decrease median arrival to revascularization time, thus increasing the potential for good functional outcome. Methods: The study includes a pre- and post-intervention retrospective review of patients 18 years or older, hospital admission between January 1, 2014 and December 31, 2015, who underwent EVT for treatment acute ischemic stroke. The primary outcome variable was time from arrival to revascularization during the acute ischemic stroke admission. The secondary outcome variables were specific to functional outcome analysis in the acute ischemic stroke patient. The data points were collected from the local America Heart Association’s Get with the Guidelines-Stroke (GWTG) dataset. Results: Twenty eight consecutive endovascular ischemic stroke patients were reviewed, pre process improvement (PI) (Group 1, n=10) and post PI (Group 2, n=18). There were no significant differences between baseline characteristics between the groups. The primary outcome analysis revealed significant improvement in door to revascularization between the pre and post PI groups, 2:56 and 2:11 (p=.002) respectively, a 45 minute decrease in time to treatment. Rates of good clinical outcomes (modified Rankin Scale 0-2 at 3 months) were similar in both groups, 33.3% pre PI and 46.2% post PI (p=0.59). Conclusions: Hospital based PI initiatives including: early notification, streamlined transport process, and utilization of feedback tool significantly improve door to revascularization times and can potentially lead to improved functional outcomes in the acute ischemic stroke patient undergoing EVT.

Download Full-text

Treatment and Outcomes of Patients With Ischemic Stroke During COVID-19: An Analysis From Get With The Guidelines-Stroke

Stroke ◽

10.1161/strokeaha.120.034414 ◽

2021 ◽

Author(s):

Pratyaksh K. Srivastava ◽

Shuaiqi Zhang ◽

Ying Xian ◽

Hanzhang Xu ◽

Christine Rutan ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Endovascular Therapy ◽

Stroke Care ◽

The United States ◽

National Registry ◽

Acute Stroke Care ◽

Hospital Outcomes ◽

Time Period ◽

Get With The Guidelines

Background and Purpose: The coronavirus disease 2019 (COVID-19) pandemic has created challenges in the delivery of acute stroke care. In this study, we analyze the characteristics, evaluation, treatment, and in-hospital outcomes of patients presenting with acute ischemic stroke (AIS) pre-COVID-19 and during COVID-19. Methods: Get With The Guidelines-Stroke is a national registry of adults with stroke in the United States. Using this registry, we identified patients with a diagnosis of AIS before (n=39 113; November 1, 2019–February 3, 2020) and after (n=41 971; February 4, 2020–June 29, 2020) the first reported case of COVID-19 in the registry. Characteristics, treatment patterns, quality metrics, and in-hospital outcomes were compared between the 2 groups. Results: Stroke presentations decreased by an average of 15.3% per week in the during COVID-19 time period when compared with similar months in 2019. Compared with patients with AIS in the pre-COVID-19 era, patients in the COVID-19 time period had similar rates of intravenous alteplase and endovascular therapy, and similar door to computed tomography, door to needle, and door to endovascular therapy times. In adjusted models, inpatient mortality was similar between those presenting with AIS pre-COVID-19 and during COVID-19 (4.8% versus 5.2%; odds ratio, 1.05 [95% CI, 0.97–1.13]). Conclusions: Among hospitals participating in Get With The Guidelines-Stroke, patients presenting with AIS during COVID-19 received, with few exceptions, similar quality care and experienced similar risk-adjusted outcomes when compared with patients with AIS presenting pre-COVID-19. These findings demonstrate that stroke care in the United States remains robust during the COVID-19 pandemic.

Download Full-text