Early transition to comfort measures only in acute stroke patients

AbstractBackground:Death after acute stroke often occurs after forgoing life-sustaining interventions. We sought to determine the patient and hospital characteristics associated with an early decision to transition to comfort measures only (CMO) after ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) in the Get With The Guidelines–Stroke registry.Methods:We identified patients with IS, ICH, or SAH between November 2009 and September 2013 who met study criteria. Early CMO was defined as the withdrawal of life-sustaining treatments and interventions by hospital day 0 or 1. Using multivariable logistic regression, we identified patient and hospital factors associated with an early (by hospital day 0 or 1) CMO order.Results:Among 963,525 patients from 1,675 hospitals, 54,794 (5.6%) had an early CMO order (IS: 3.0%; ICH: 19.4%; SAH: 13.1%). Early CMO use varied widely by hospital (range 0.6%–37.6% overall) and declined over time (from 6.1% in 2009 to 5.4% in 2013; p < 0.001). In multivariable analysis, older age, female sex, white race, Medicaid and self-pay/no insurance, arrival by ambulance, arrival off-hours, baseline nonambulatory status, and stroke type were independently associated with early CMO use (vs no early CMO). The correlation between hospital-level risk-adjusted mortality and the use of early CMO was stronger for SAH (r = 0.52) and ICH (r = 0.50) than AIS (r = 0.15) patients.Conclusions:Early CMO was utilized in about 5% of stroke patients, being more common in ICH and SAH than IS. Early CMO use varies widely between hospitals and is influenced by patient and hospital characteristics.

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Assessment and provision of rehabilitation among patients hospitalized with acute ischemic stroke in China: Findings from the China National Stroke Registry II

International Journal of Stroke ◽

10.1177/1747493017701945 ◽

2017 ◽

Vol 12 (3) ◽

pp. 254-263 ◽

Cited By ~ 8

Author(s):

Janet Prvu Bettger ◽

Zixiao Li ◽

Ying Xian ◽

Liping Liu ◽

Xingquan Zhao ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Multivariable Analysis ◽

Thrombosis Prophylaxis ◽

Stroke Patients ◽

Multivariable Logistic Regression Model ◽

Recommended Care ◽

Stroke Registry ◽

Factors Associated ◽

Rehabilitation Assessment

Background Stroke rehabilitation improves functional recovery among stroke patients. However, little is known about clinical practice in China regarding the assessment and provision of rehabilitation among patients with acute ischemic stroke. Aims We examined the frequency and determinants of an assessment for rehabilitation among acute ischemic stroke patients from the China National Stroke Registry II. Methods Data for 19,294 acute ischemic stroke patients admitted to 219 hospitals from June 2012 to January 2013 were analyzed. The multivariable logistic regression model with the generalized estimating equation method accounting for in-hospital clustering was used to identify patient and hospital factors associated with having a rehabilitation assessment during the acute hospitalization. Results Among 19,294 acute ischemic stroke patients, 11,451 (59.4%) were assessed for rehabilitation. Rates of rehabilitation assessment varied among 219 hospitals (IQR 41.4% vs 81.5%). In the multivariable analysis, factors associated with increased likelihood of a rehabilitation assessment ( p < 0.05) included disability prior to stroke, higher NIHSS on admission, receipt of a dysphagia screen, deep venous thrombosis prophylaxis, carotid vessel imaging, longer length of stay, and treatment at a hospital with a higher number of hospital beds (per 100 units). In contrast, patients with a history of atrial fibrillation and hospitals with higher number of annual stroke discharges (per 100 patients) were less likely to receive rehabilitation assessment during the acute stroke hospitalization. Conclusions Rehabilitation assessment among acute ischemic stroke patients was suboptimal in China. Rates varied considerably among hospitals and support the need to improve adherence to recommended care for stroke survivors.

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Cryptogenic stroke

Neurology Clinical Practice ◽

10.1212/cpj.0000000000000736 ◽

2019 ◽

Vol 10 (5) ◽

pp. 396-405

Author(s):

Shyam Prabhakaran ◽

Steven R. Messé ◽

Dawn Kleindorfer ◽

Eric E. Smith ◽

Gregg C. Fonarow ◽

...

Keyword(s):

Multivariable Analysis ◽

Cryptogenic Stroke ◽

National Institutes Of Health ◽

Large Artery ◽

Vessel Occlusion ◽

Stroke Registry ◽

Stroke Etiology ◽

Discharge Outcomes ◽

Get With The Guidelines ◽

Hospital Characteristics

BackgroundNationwide data on patients with cryptogenic stroke (CS) are lacking. We evaluated patient and hospital characteristics, in-hospital treatments, and discharge outcomes among patients with CS compared with other subtypes in the Get With The Guidelines (GWTG)-Stroke registry.MethodsWe identified patients with ischemic stroke (IS) admitted to GWTG-Stroke participating hospitals between January 1, 2016, and September 30, 2017, with documented National Institutes of Health Stroke Scale (NIHSS) scale and stroke etiology (cardioembolic [CE], large artery atherosclerosis [LAA], small vessel occlusion [SVO], other determined etiology [OTH], or CS). Using multivariable logistic regression, we compared hospital treatments and discharge outcomes by subtype, adjusted for patient and hospital characteristics.ResultsAmong 316,623 patients from 1,687 hospitals, there were 63,301 (20.0%) patients with CS. In multivariable analysis, patients with CS received IV thrombolysis more often than other subtypes and had lower mortality than CE, LAA, and OTH but higher mortality than SVO. They were more likely to be discharged home than all other subtypes and be independent at discharge than LAA, OTH, or SVO.ConclusionsIn a large contemporary nationwide registry, CS accounted for 20% of ISs among patients with a documented stroke etiology. Patients with CS had a distinct profile of treatments and outcomes relative to other subtypes. Improved subtype documentation and further research into CS are warranted to improve care and outcomes for patients with stroke.

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Abstract W P57: Thrombolytic Therapy in Patients With Mild Stroke: An Observational Study

Stroke ◽

10.1161/str.45.suppl_1.wp57 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Jose G Romano ◽

Eric E Smith ◽

Li Liang ◽

Hannah Gardener ◽

Sara Camp ◽

...

Keyword(s):

Ischemic Stroke ◽

Multivariable Analysis ◽

Hospital Death ◽

Stroke Patients ◽

Short Term ◽

Stroke Registry ◽

Symptomatic Intracranial Hemorrhage ◽

Mild Stroke ◽

Independent Ambulation ◽

Get With The Guidelines

Objective: Mild stroke has traditionally been excluded from thrombolytic treatment trials and only few series have reported outcomes after IV rtPA in this group. The objectives of this study are to determine the proportion of mild stroke patients treated with IV rtPA and evaluate complications and short-term outcomes in this population. Methods: We analyzed patients in the Get With The Guidelines-Stroke registry that arrived within 4.5 hours from symptom onset with a mild ischemic stroke defined as a baseline NIHSS ≤5 who received IV rtPA between May 2010 and October 2012. The following outcomes and complications were analyzed: in-hospital mortality, home discharge, independent ambulation, length of stay (LOS), in-hospital death, and symptomatic intracranial hemorrhage (sICH) <36 h. Multivariable analysis was performed for predictors of outcomes and complications. Results: Of 147,917 patients who arrived <4.5 hours, 39,821 were treated with IV rtPA, of whom 8,243 (20.7%) had an NIHSS ≤5. We analyzed 5,910 treated patients with NIHSS ≤5 and complete data. The mean baseline NIHSS was 3.5 (median 4); 98.2% arrived within 3 hours and 78.6% were treated within 3 hours. Outcomes and predictors of worse outcome are described in the table. There was no difference in short-term outcomes amongst those treated at 0-3 vs. 3-4.5 hours. Conclusions: A sizeable minority of ischemic stroke patients treated with IV rtPA have a NIHSS ≤5. sICH occurred at a low rate of 1.8% and about 30% of these patients were unable to return home and could not ambulate independently. Longer-term outcomes are needed to define predictors of poor outcome in this population and which patients may benefit most from treatment.

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Abstract T MP80: Comparison of ICD-9-CM and Clinical Diagnoses for Stroke Patients in the Paul Coverdell National Acute Stroke Registry, 2013

Stroke ◽

10.1161/str.46.suppl_1.tmp80 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Tiffany E Chang ◽

Mary G George

Keyword(s):

Acute Stroke ◽

Performance Measures ◽

Hemorrhagic Stroke ◽

P Value ◽

Stroke Patients ◽

Stroke Registry ◽

Clinical Diagnoses ◽

Improved Performance ◽

Stroke Type ◽

Ischemic Attack

Background: Few large studies have examined the comparison of ICD-9-CM codes and clinical diagnoses (CDX) for acute stroke patients. We analyzed the concordance between these two coding systems for patients entered in the Paul Coverdell National Acute Stroke Registry (PCNASR). We hypothesized that discordance between patient-level ICD-9-CM codes and clinical diagnoses will result in differences in outcomes on stroke performance measures (PMs). Methods: Eleven states submitted 90,035 records between Jan 1 and Dec 31, 2013. In-hospital strokes and records with multiple or missing CDXs were excluded from the analysis, resulting in a final sample size of 85,024. Clinical diagnoses were defined as: ischemic stroke (IS), transient ischemic attack (TIA), subarachnoid hemorrhagic stroke (SAH), intracerebral hemorrhagic stroke (ICH), stroke not specified (SNS), admission for carotid intervention only (CI), and other. Data was analyzed by comparing the documented principal ICD-9-CM code and final CDX of each patient. Any discordance between ICD-9-CM codes and CDX was analyzed further by examining its effect on outcomes of ten stroke performance measures (PMs) collected by PCNASR. Results: The agreement rate between ICD-9-CM codes and clinical diagnoses differs by stroke type (94.1% (IS) to 1.6% (SNS)) (Table 1). Discordance in diagnosis led to differences in outcomes on stroke PMs (range: difference of 0.1-1.03 percentage points; p-value < 0.05 for 5 measures), with 8 out of the 10 PMs having improved performance when ICD-9-CM codes are used (data not shown). Using only cases where the CDX is the same as the ICD-9-CM results in even higher adherence to PMs. Conclusion: In conclusion, due to discrepancies between ICD-9-CM codes and clinical diagnoses, outcomes on stroke PMs can vary significantly, depending on the diagnosis method used.

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Abstract W MP99: Race/Ethnic and Sex Differences in EMS Transport among Hospitalized U.S. Stroke Patients: Analysis of the National Get With The Guidelines-Stroke Registry

Stroke ◽

10.1161/str.46.suppl_1.wmp99 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Heidi Mochari-Greenberger ◽

Ying Xian ◽

Anne S Hellkamp ◽

Phillip J Schulte ◽

Deepak L Bhatt ◽

...

Keyword(s):

Ethnic Group ◽

Insurance Coverage ◽

Health Insurance Coverage ◽

National Sample ◽

Stroke Patients ◽

Hispanic Males ◽

Stroke Registry ◽

Black Females ◽

History Of ◽

Get With The Guidelines

Background: Calling 911 is the recommended first step when stroke symptoms occur. Differences in activation of emergency medical services (EMS) may contribute to race/ethnic and sex disparities in stroke outcomes. The purpose of this study was to determine whether EMS utilization varies among a contemporary, diverse national sample of hospitalized acute stroke patients. Methods: We analyzed data from 398,798 stroke patients admitted to 1,613 Get With The Guidelines-Stroke participating hospitals from 10/1/11-3/31/14. Multivariable logistic regression was utilized to evaluate the associations between race/ethnic group and sex, with EMS use, adjusting for potential confounders. Results: Patients were 50.4% female, 69% white, 19% black, 8% Hispanic, 3% Asian, 1% other; 85.9% ischemic stroke. Overall 58.6% of stroke patients were transported to the hospital by EMS. EMS utilization differed by sex and race/ethnic group (interaction p<0.001). White females were most likely to use EMS (62.0%) and Hispanic males were least likely to (52.2%). Age, health insurance coverage, and history of prior stroke or TIA varied significantly among race/ethnic groups (p<0.0001). After adjustment for both patient and hospital characteristics, Hispanic and Asian men and women were less likely than their white counterparts to utilize EMS; black females were less likely than white females to utilize EMS (Table). Conclusion: EMS use was low overall and differential by race/ethnicity and sex. These contemporary data support a need for targeted initiatives to increase EMS transport among U.S. stroke patients.

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Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Stroke ◽

10.1161/str.45.suppl_1.tp267 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Kerrin Connelly ◽

Rishi Gupta ◽

Raul Nogueira ◽

Arthur Yancey ◽

Alexander Isakov ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Transport Protocol ◽

Stroke Patients ◽

Stroke Registry ◽

The Public ◽

State Office ◽

Stroke Center ◽

Iv Tpa

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

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Abstract T P299: Ambulatory Status: A Protective Mechanism against Venous Thromboembolism in Acute Stroke Patients

Stroke ◽

10.1161/str.46.suppl_1.tp299 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Jason-Flor Sisante ◽

Michael Abraham ◽

Sandra Billinger ◽

Manoj Mittal

Keyword(s):

Venous Thromboembolism ◽

Subarachnoid Hemorrhage ◽

Intracerebral Hemorrhage ◽

Acute Stroke ◽

Early Mobilization ◽

Protective Mechanism ◽

Stroke Patients ◽

Ambulatory Status ◽

Stroke Type ◽

The Relationship

Introduction: Deep vein thrombosis (DVT) is reported in 23% to 50% of hemiplegic stroke survivors and the highest rate of incidence occurs within one week of stroke onset. Pulmonary embolism (PE) is reported in up to 5% of stroke patients. There is limited data about the relationship of ambulatory status and the rate of venous thromboembolism (VTE) following a stroke. Hypothesis: The goal of our retrospective cohort study was to understand the relationship between VTE and a patient’s ambulatory status, adjusting for age, gender, and stroke type (ischemic, intracerebral hemorrhage, or subarachnoid hemorrhage). We assessed the hypothesis that the stroke patients who are able to ambulate during hospitalization would have lower rates of DVT and PE. Methods: We retrospectively analyzed 1670 acute stroke patients who were admitted to an academic comprehensive stroke center between Feb 2006 and May 2014. “Get with the guideline data” was used to identify stroke patients and their ambulatory status (yes/no). VTE was identified using discharge diagnosis. Chi square test and logistic regression methods were used for statistical analysis. Results: Mean age was 64.9 ± 14.6 years with 51% men. 1138 (68%) patients were classified as having ischemic stroke; 291 (17.5%) patients had intracerebral hemorrhage; and 241 (14.5%) patients had subarachnoid hemorrhage. During hospitalization, 444 (27%) were ambulatory. Patients able to ambulate during hospitalization had less rate of DVT (6.3% vs 15.3%; p<0.0001) and PE (2.9% vs 5.3%; p=0.04), when compared to non-ambulating patients. After adjusting for age, gender, and stroke type; patients who were able to ambulate still had lower rates of DVT (OR: 0.42, 95% CI 0.27-0.63) and PE (OR: 0.49, 95% CI 0.25-0.88). Conclusion: In conclusion, our findings suggest that the patient’s ambulatory status during hospitalization is an independent predictor of VTE. Further research is needed to understand if early mobilization in non-ambulatory stroke patients would have similar protective effect against VTE or not.

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Abstract TP205: Clinical Aspects Of First-ever Stroke In Patients With Permanent Pacemaker

Stroke ◽

10.1161/str.44.suppl_1.atp205 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Jiro Kitayama ◽

Hiroshi Nakane ◽

Hiromi Ishikawa ◽

Masahiro Shijo ◽

Masahiro Kamouchi ◽

...

Keyword(s):

Acute Stroke ◽

Pacemaker Implantation ◽

The United States ◽

Permanent Pacemaker ◽

Stroke Onset ◽

Clinical Aspects ◽

Stroke Patients ◽

Stroke Treatment ◽

Stroke Registry ◽

History Of

OBJECTIVES: Recently, increasing numbers of patients take pacemaker implantation: almost sixty thousands in Japan, and no less than two hundreds of thousands in the United States per year. Previous reports have indicated that prevalence of atrial fibrillation (Af) is high, and several coagulation markers are elevated in those with pacemaker. However, the precise features of stroke with implanted device are not clear. We, thus, examined the clinical aspects of stroke in pacemaker patients. METHODS: For the present study, we analyzed data from the Fukuoka Stroke Registry that is a multicenter epidemiological study database on acute stroke. From June 1999 to May 2011, 11376 ischemic stroke patients (72±12 years of age, female/male=4613/6763) who admitted to the hospital within seven days after onset were enrolled in the registry. Stroke subtypes were classified according to the diagnostic criteria of TOAST (Trial of Org 10172 in Acute Stroke Treatment). RESULTS: A total of 207 patients (1.8% of registered stroke patients) were with pacemaker. Among them, 130 patients had no history of any stroke. They appeared to be a mean age of 81±9 (range 42 to 97) years, and female/male ratio of 77/53. Mean duration from pacemaker implantation to stroke onset was 8±7 (median 6, quartile 3-11) years. 32 patients (25%) were given oral anticoagulant prior to stroke onset; 60 (46%) were on antiplatelet. Prevalence of Af in pacemaker patients was 48% (n=63). In those with Af, 48 patients (76%) were diagnosed as cardioembolic stroke, but only 22 (35%) were on anticoagulation before onset. Even in those without Af, 33 cases (49%) were also diagnosed as cardioembolic. The percentage of subjects with increased plasma D-dimer (≥1.5 μg/ml) was significantly higher in pacemaker group than no-pacemaker group, regardless of the presence or absence of Af (75% vs. 45% with Af; p<0.0001, 74% vs. 25% without Af; p<0.0001). CONCLUSIONS: In our current study, stroke in pacemaker patients revealed to have higher incidence of cardiogenic embolism, with or without Af. In addition, the majority was elderly, and failed to receive anticoagulant prior to stroke. It is needed to re-consider therapeutic strategy, including anticoagulation, for prevention of stroke in those with permanent pacemaker.

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Clinical factors associated with statins prescription in acute ischemic stroke patients: findings from the Lombardia Stroke Registry

BMC Neurology ◽

10.1186/1471-2377-14-53 ◽

2014 ◽

Vol 14 (1) ◽

Cited By ~ 5

Author(s):

Isabella Canavero ◽

Anna Cavallini ◽

Patrizia Perrone ◽

Mauro Magoni ◽

Lucia Sacchi ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Factors ◽

Stroke Patients ◽

Stroke Registry ◽

Factors Associated

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Factors associated with late arrival of acute stroke patients to emergency department in Saudi Arabia

SAGE Open Medicine ◽

10.1177/2050312118776719 ◽

2018 ◽

Vol 6 ◽

pp. 205031211877671 ◽

Cited By ~ 4

Author(s):

Ali M Al Khathaami ◽

Yasmeen O Mohammad ◽

Fatimah S Alibrahim ◽

Hoda A Jradi

Keyword(s):

Emergency Department ◽

Saudi Arabia ◽

Acute Stroke ◽

Delayed Presentation ◽

Stroke Patients ◽

Cross Sectional Survey ◽

Community Based Interventions ◽

Cross Sectional ◽

Factors Associated ◽

Late Arrival

Background: Tissue plasminogen activator within 4.5 h of onset is effective for acute ischemic stroke. However, only small proportion of patients is treated due to delayed presentation. We aimed to examine the factors associated with delays of stroke patients in Riyadh, Saudi Arabia. Methods: A cross-sectional survey was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, during a 6-month period. An interviewer administered structured questionnaire addressed to the acute stroke patients or their relatives was used to explore the factors associated with delayed arrival. Results: A total of 227 patients attending the emergency department were interviewed. The mean age was 60.4 ± 15.6 years. Approximately 56.4% presented after 4.5 h of stroke onset. Factors associated with late arrival were being alone during the onset of stroke, not being transported in an ambulance, not knowing that they were experiencing a stroke, and residing outside the city of Riyadh. Conclusion: More than half of patients missed the golden hours for thrombolysis due to delayed presentation. Reasons include lack of knowledge, underuse of ambulance and difficult access to care. Urgent community-based interventions are needed to address these factors.

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