Acute stroke treatment and outcome in the oldest old (90 years and older) at a tertiary care medical centre in Germany-a retrospective study showing safety and efficacy in this particular patient population

Background Stroke is among the most common causes of death and disability worldwide. Despite the relevance of stroke-related disease burden, which is constantly increasing due to the demographic change in industrialized countries with an ageing population and consecutively an increase in age-associated diseases, there is sparse evidence concerning acute stroke treatment and treatment-related outcome in the elderly patient group. This retrospective study aimed at analysing patient characteristics, therapy-related complications and functional outcome in stroke patients aged 90 years or older who underwent acute stroke treatment (i.e. intravenous thrombolysis, mechanical thrombectomy, or both). Methods We identified files of all inpatient stays at the Department of Neurology at Saarland University Medical Center (tertiary care level with a comprehensive stroke unit) between June 2011 and December 2018 and filtered for subjects aged 90 years or older at the time of admission. We reviewed patient files for demographic data, symptoms upon admission, (main) diagnoses, comorbidities, and administered therapies. For patients admitted due to acute stroke we reviewed files for therapy-related complications and functional outcome. We compared the modified Rankin scale (mRS) scores upon admission and at discharge for these patients. Results We identified 566 inpatient stays of subjects aged 90 years or older. Three hundred sixty-seven of the 566 patients (64.8%) were admitted and discharged due to symptoms indicative of stroke. Two hundred eleven patients received a diagnosis of ischaemic stroke. These 211 patients were analysed subsequently. Sixty-four patients qualified for acute stroke treatment (intravenous thrombolysis n = 22, mechanical thrombectomy n = 26, intravenous thrombolysis followed by mechanical thrombectomy n = 16) and showed a significant improvement in their functional status as measured by change in mRS score (admission vs. discharge, p 0.001) with 7 (10.9%) observed potentially therapy-related complications (relevant drop in haemoglobin n = 2, subarachnoidal haemorrhage n = 1, cerebral haemorrhage n = 3, extracranial bleeding n = 1). One intravenous thrombolysis was stopped because of an uncontrollable hypertensive crisis. Patients who did not qualify for these treatments (including those declining acute treatment) did not show a change of their functional status between admission and discharge (p 0.064). Conclusion Our data indicate that acute stroke treatment is effective and safe in the oldest old. Age alone is no criterion to withhold an acute intervention even in oldest old stroke patients.

Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

<b><i>Background and Purpose:</i></b> Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. <b><i>Methods:</i></b> In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. <b><i>Results:</i></b> From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (<i>p</i> &#x3c; 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (<i>p</i> &#x3c; 0.001). <b><i>Conclusions:</i></b> Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

Regular hours vs. on-call endovascular interventions for acute stroke treatment: initial single-center experience by interventional cardiologists

Background Endovascular treatment for acute stroke with large vessel occlusion became the mainstay therapy but remains limited due to lack of trainees and specialized centers. To offer this therapeutical option to a vast population, interventional cardiologists joined interdisciplinary stroke teams. Because of limited experience, it remains unclear if the timing of the procedure (i.e., regular hours vs. on-call time) may influence quality, time-effectiveness and outcomes. Purpose To investigate if the timing of the procedure (i.e., regular hours vs. on-call time) significantly influences procedural parameters and outcomes of patients undergoing acute endovascular stroke treatment. Methods Consecutive patients undergoing acute endovascular stroke treatment from 07/2012 – 10/2020, treated by cardiologists, were reviewed. Baseline characteristics, procedural aspects and clinical outcomes were retrospectively collected. Cases were divided into two groups, depending on the timing of the procedure: on-call time (OC, i.e., weekend days, public holidays and documented “call in” of the on-call service) vs. regular hours (RH, i.e., all other procedures) and outcomes subsequently compared. Results One-hundred-thirteen consecutive patients underwent endovascular treatment for acute stroke; of those 77 (68.1%) during regular hours and 36 (31.9%) during on-call time. Patients were in their early 70ies and risk factors such as arterial hypertension, diabetes mellitus, dyslipidemia and atrial fibrillation were evenly distributed. Modified Ranking Scale (mRS) at presentation was 5 in both groups and decreased to 3 at discharge. The anterior circulation was most often affected (RH: 90.9% vs. OC: 94.4%, p=0.518) and a stent retriever only strategy commonly chosen (RH: 42.8% vs. OC: 30.5%, p=0.211), followed by a combined approach of stent retriever use and aspiration (RH: 25.9% vs. OC: 27.7%, p=0.752). Door-to-needle time (RH: 0:55h IQR [0:45–1:22] vs. OC: 1:05h IQR [0:54–1:30], p=0.237) and procedure duration (RH: 0:48h IQR [0:30–1:25] vs. OC: 0:58h IQR [0:35–1:46], p=0.214) were comparable. Contrast agent use and radiation time (RH: 17.6 min IQR [11.7–29.3] vs. OC: 17.6 min IQR [12.1–33.6]) did not differ between groups, however patients in the OC group experienced a higher dose area product (RH: 4827mGy cm2 IQR [1567–14092] vs. 12727mGy cm2 [6732–18889], p&lt;0.001). The combined quality endpoint, comprising of TICI IIb/III flow after the procedure, no embolization to new territory and no symptomatic intracranial bleeding during in hospital stay was met in 85.5% of patients in the RH group and 80.5% of the on-call group (p=0.485). Death during in-hospital stay was observed in 22% of patients in the RH group and 11.1% of the OC group (p=0.163). Conclusions Endovascular intervention for acute stroke treatment during on-call time is as effective and safe as if performed during regular hours but associated with a higher dose area product. FUNDunding Acknowledgement Type of funding sources: None.

Acute Reperfusion Therapies for Acute Ischemic Stroke

The field of acute stroke treatment has made tremendous progress in reducing the overall burden of disability. Understanding the pathophysiology of acute ischemic injury, neuroimaging to quantify the extent of penumbra and infarction, and acute stroke reperfusion therapies have together contributed to these advancements. In this review we highlight advancements in reperfusion therapies for acute ischemic stroke.

A step toward understanding the mechanism of action of audit and feedback: a qualitative study of implementation strategies

Background Audit and feedback (A&F) is a widely used implementation strategy. Understanding mechanisms of action of A&F increases the likelihood that the strategy will lead to implementation of an evidence-based practice. We therefore sought to understand one hospital’s experience selecting and implementing an A&F intervention, to determine the implementation strategies that were used by staff and to specify the mechanism of action of those implementation strategies using causal pathway models, with the ultimate goal of improving acute stroke treatment practices. Methods We selected an A&F strategy in a hospital, initially based on implementation determinants and staff consideration of their performance on acute stroke treatment measures. After 7 months of A&F, we conducted semi-structured interviews of hospital providers and administrative staff to understand how it contributed to implementing guideline-concordant acute stroke treatment (medication named tissue plasminogen activator). We coded the interviews to identify the implementation strategies that staff used following A&F and to assess their mechanisms of action. Results We identified five implementation strategies that staff used following the feedback intervention. These included (1) creating folders containing the acute stroke treatment protocol for the emergency department, (2) educating providers about the protocol for acute stroke, (3) obtaining computed tomography imaging of stroke patients immediately upon emergency department arrival, (4) increasing access to acute stroke medical treatment in the emergency department, and (5) providing additional staff support for implementation of the protocol in the emergency department. We identified enablement, training, and environmental restructuring as mechanisms of action through which the implementation strategies acted to improve guideline-concordant and timely acute stroke treatment. Conclusions A&F of a hospital’s acute stroke treatment practices generated additional implementation strategies that acted through various mechanisms of action. Future studies should focus on how initial implementation strategies can be amplified through internal mechanisms.

Challenges of Outcome Prediction for Acute Stroke Treatment Decisions

Physicians often base their decisions to offer acute stroke therapies to patients around the question of whether the patient will benefit from treatment. This has led to a plethora of attempts at accurate outcome prediction for acute ischemic stroke treatment, which have evolved in complexity over the years. In theory, physicians could eventually use such models to make a prediction about the treatment outcome for a given patient by plugging in a combination of demographic, clinical, laboratory, and imaging variables. In this article, we highlight the importance of considering the limits and nuances of outcome prediction models and their applicability in the clinical setting. From the clinical perspective of decision-making about acute treatment, we argue that it is important to consider 4 main questions about a given prediction model: (1) what outcome is being predicted, (2) what patients contributed to the model, (3) what variables are in the model (considering their quantifiability, knowability at the time of decision-making, and modifiability), and (4) what is the intended purpose of the model? We discuss relevant aspects of these questions, accompanied by clinically relevant examples. By acknowledging the limits of outcome prediction for acute stroke therapies, we can incorporate them into our decision-making more meaningfully, critically examining their contents, outcomes, and intentions before heeding their predictions. By rigorously identifying and optimizing modifiable variables in such models, we can be empowered rather than paralyzed by them.