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

BACKGROUND: Despite its approval for acute ischemic stroke >25 years ago, intravenous thrombolysis (IVT) remains underused, with inequities by age, sex, race, ethnicity, and geography. Little is known about IVT rates by insurance status. METHODS AND RESULTS: We assessed temporal trends from 2002 to 2015 in IVT for acute ischemic stroke in the Nationwide Inpatient Sample using adjusted, survey-weighted logistic regression. We calculated odds ratios for IVT for each category in 2002 to 2008 (period 1) and 2009 to 2015 (period 2). IVT use for acute ischemic stroke increased from 1.0% in 2002 to 6.8% in 2015 (adjusted annual relative ratio, 1.15). Individuals aged ≥85 years had the most pronounced increase during 2002 to 2015 (adjusted annual relative ratio, 1.18) but were less likely to receive IVT compared with 18- to 44-year-olds in period 1 (adjusted odds ratio [aOR], 0.23) and period 2 (aOR, 0.36). Women were less likely than men to receive IVT, but the disparity narrowed over time (period 1: aOR, 0.81; period 2: aOR, 0.94). Inequities in IVT resolved for Hispanic individuals in period 2 (aOR, 0.96) but not for Black individuals (period 2: aOR, 0.81). The disparity in IVT for Medicare patients, compared with privately insured patients, lessened over time (period 1: aOR, 0.59; period 2: aOR, 0.75). Patients treated in rural hospitals remained less likely to receive IVT than in urban hospitals; a more dramatic increase in urbanity widened the inequity (period 2, urban nonteaching versus rural: aOR, 2.58, period 2, urban teaching versus rural: aOR, 3.90). CONCLUSIONS: IVT for acute ischemic stroke increased among adults. Despite some encouraging trends, the remaining disparities highlight the need for intensified efforts at addressing inequities.

Renal disease is not associated with delays in hyperacute stroke management in South Australia.

OBJECTIVE: The aims of the present study were to determine how renal disease is associated with the time to receive hyperacute stroke care. METHODS: The present study involved a 5-year cohort of all patients admitted to stroke units in South Australia. RESULTS: In those with pre-existing renal disease there were no significant differences in the time taken to receive a scan, thrombolysis or endovascular thrombectomy. CONCLUSIONS: The present study shows that in protocolised settings there were no significant delays in hyperacute stroke management for patients with renal disease.

Informing Utstein-style reporting guidelines for prehospital thrombolysis: A scoping review.

BACKGROUND: Rural Australians with acute myocardial infarction (AMI) face higher mortality rates due to limited access to specialised cardiac services. Paramedic-administered prehospital thrombolysis (PHT) has emerged as an alternative to primary percutaneous intervention (pPCI) for patients facing barriers or delays to cardiac care. There is variability in PHT practices among Australian ambulance services, lacking standardised definitions and outcome measures. The aim of this scoping review was to identify quality indicators and influencing factors associated with outcomes for patients receiving PHT. METHODS: A systematic search of literature in SCOPUS and Academic Search Complete, CINAHL and Health Source: Nursing/Academic Edition databases via EBSCO (Health) was conducted following the Joanna Briggs Institute methodology. Peer-reviewed studies from the past decade were screened using search criteria relevant to prehospital thrombolysis and quality indicators. Data extraction was performed and themed using five domains from the Utstein-style template commonly known for standardised prehospital cardiac arrest reporting. RESULTS: After removing duplicates, the search yielded 3596 articles with 28 empirical studies meeting inclusion criteria for the review. These were primarily retrospective cohort studies performed in Australia, Canada and the United States. The scoping review identified 24 clinical quality indicators and factors related to Emergency Medical Service (EMS) systems, AMI recognition and ambulance dispatch, patient variables, PHT processes and patient outcomes. These findings correlate to the Donabedian structure-process-outcome quality of care model and have utility to inform future PHT reporting guidelines for jurisdictional ambulance services. CONCLUSIONS: Given the variability in prehospital practice across Australian ambulance services, standardised reporting on quality indicators for PHT is needed. The Utstein-style template used to report data on pre-hospital cardiac arrest, trauma and airway management could be used for quality improvement in PHT. This review presents 24 quality indicators representing system, recognition and response, patient, process, and outcomes related to PHT. These results could be used to inform a future Delphi study and Utstein-like reporting guideline for prehospital thrombolysis.

Certification of stroke centers at primary hospitals and the improvement of thrombolysis n South China during 2020-2022.

INTRODUCTION: IVT use declined globally in 2020 due to the Corona Virus Disease 2019 (COVID-19) pandemic, but it increased in South China. This study was conducted to evaluate the association of establishing Stroke Prevention Centers (SPCs) at primary hospitals with IVT increase in South China. MATERIALS AND METHODS: We conducted a longitudinal observational study across 336 hospitals in 114 areas in South China during 2020-2022. Data regarding certified stroke centers, IVT volumes, and IVT rates were collected. Correlations between IVT rates and the number or density of stroke centers were accessed. IVT use was compared among areas with different levels of stroke centers or on different certification process. RESULTS: During 2020-2022, there were 83, 125, and 152 stroke centers, with 26, 65, and 92 SPCs, respectively. IVT therapies were 12,795, 17,266, and 20,411, representing a 29.8% increase/year (all p < 0.001). IVT rates increased from 7.2% in 2020 to 8.8% and 10.4% in 2021 and 2022, demonstrating a 22.2% increase/year (all p < 0.001). IVT rates correlated with the number and density of SPCs (all p < 0.05). IVT rates were higher in areas equipped with SPCs than in those without stroke centers (all p < 0.05). IVT rates consistently increased during the SPC certification process from 1 year before through the certification and subsequent maintenance (both p < 0.05). DISCUSSION AND CONCLUSION: Well-organised SPCs and IVT therapy demonstrated substantial increase during the 3-year period. Certification of SPCs at primary hospitals is associated with improved IVT therapy in South China even with city lockdown during COVID-19 pandemic.

Rural-Urban Disparities in Outcomes of Myocardial Infarction, Heart Failure, and Stroke in the United States.

BACKGROUND: U.S. policy efforts have focused on reducing rural-urban health inequities. However, it is unclear whether gaps in care and outcomes remain among older adults with acute cardiovascular conditions. OBJECTIVES: This study aims to evaluate rural-urban differences in procedural care and mortality for acute myocardial infarction (AMI), heart failure (HF), and ischemic stroke. METHODS: This is a retrospective cross-sectional study of Medicare fee-for-service beneficiaries aged ≥65 years with acute cardiovascular conditions from 2016 to 2018. Cox proportional hazards models with random hospital intercepts were fit to examine the association of presenting to a rural (vs urban) hospital and 30- and 90-day patient-level mortality. RESULTS: There were 2,182,903 Medicare patients hospitalized with AMI, HF, or ischemic stroke from 2016 to 2018. Patients with AMI were less likely to undergo cardiac catherization (49.7% vs 63.6%, P < 0.001), percutaneous coronary intervention (42.1% vs 45.7%, P < 0.001) or coronary artery bypass graft (9.0% vs 10.2%, P < 0.001) within 30 days at rural versus urban hospitals. Thrombolysis rates (3.1% vs 10.1%, P < 0.001) and endovascular therapy (1.8% vs 3.6%, P < 0.001) for ischemic stroke were lower at rural hospitals. After adjustment for demographics and clinical comorbidities, the 30-day mortality HR was significantly higher among patients presenting to rural hospitals for AMI (HR: 1.10, 95% CI: 1.08 to 1.12), HF (HR: 1.15; 95% CI: 1.13 to 1.16), and ischemic stroke (HR: 1.20; 95% CI: 1.18 to 1.22), with similar patterns at 90 days. These differences were most pronounced for the subset of critical access hospitals that serve remote, rural areas. CONCLUSIONS: Clinical, public health, and policy efforts are needed to improve rural-urban gaps in care and outcomes for acute cardiovascular conditions.

Choice of intravenous thrombolysis therapy in patients with mild stroke complaining of acute dizziness.

BACKGROUND: Quick identification of patients with mild ischemic stroke complaining of dizziness from other patients with benign peripheral vestibular disorders who also experience dizziness in the emergency department (ED) may be difficult. Decision-making on intravenous thrombolysis therapy (IVT) in patients whose chief symptoms include acute dizziness or vertigo remains a severe challenge for ED physicians. This study evaluated the diagnosis, treatment processes and the short-term outcomes in patients with mild vestibular stroke in the ED. METHODS: A total of 89 consecutive patients with mild ischemic stroke primarily presenting with vestibular symptoms, who arrived at ED within 4.5 after onset, and were admitted at the stroke center of Zhejiang Provincial People's Hospital between January 2015 and March 2021 were retrospectively enrolled. Patients treated with IVT (n = 47) were compared to patients without IVT (n = 42) in terms of demographics, onset-to-door time (ODT), baseline clinical characteristics, risk factors of stroke, imaging findings, and short-term outcomes. The correlation between these parameters and IVT decision-making was analyzed. RESULTS: Patients in IVT group more frequently presented with shorter ODT, focal neurological deficits (dysarthria, facial palsy, hemiglossoplegia, hemiparesis, hemisensory loss), disabling deficits, higher baseline National Institute of Health Stroke Scale (NIHSS) scores, and underwent multi-mode imaging before a decision. A higher proportion of isolated vestibular symptoms, acute transient vestibular syndrome, and vestibulo-vagal symptoms were found in the no-IVT group. There were no differences in demographics between the two groups. ODT was negatively correlated with the decision-making on IVT, and baseline NIHSS scores were positively correlated with the decision-making on IVT. CONCLUSION: ODT and baseline NIHSS scores were correlated with the IVT decision in mild stroke patients primarily presenting with vestibular symptoms. Severe vestibular symptoms and disabling deficits were weakly associated with IVT decision, while the vestibulo-oculomotor signs and multi-mode imaging did not result as the influencing factors promoting the IVT decision-making for mild vestibular stroke.

Diabetes mellitus and its impact on mortality rate and outcome in pulmonary embolism.

AIMS/INTRODUCTION: In patients with pulmonary embolism (PE), the impact of diabetes mellitus on patient profile and outcome is not well investigated. MATERIAL AND METHODS: The German nationwide inpatient sample of the years 2005-2018 was analyzed. Hospitalized PE patients were stratified for diabetes, and the impact of diabetes on in-hospital events was investigated. RESULTS: Overall, 1,174,196 PE patients (53.8% aged ≥70 years, 53.5% women) and, among these, 219,550 (18.7%) diabetes patients were included. In-hospital mortality rate amounted to 15.8%, and was higher in diabetes patients than in non-diabetes patients (19.8% vs 14.8%, P < 0.001). PE patients with diabetes had a higher prevalence of cardiovascular risk factors, comorbidities, right ventricular dysfunction (31.8% vs 27.7%, P < 0.001), prolonged in-hospital stay (11.0 vs 9.0 days, P < 0.001) and higher rates of adverse in-hospital events. Remarkably, diabetes was independently associated with increased in-hospital mortality (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.20-1.23, P < 0.001) when adjusted for age, sex and comorbidities. Within the observation period of 2005-2018, a relevant decrease of in-hospital mortality in PE patients with diabetes was observed (25.5% to 16.8%). Systemic thrombolysis was more often administered to diabetes patients (OR 1.18, 95% CI 1.01-3.49, P < 0.001), and diabetes was associated with intracerebral (OR 1.19, 95% CI 1.12-1.26, P < 0.001), as well as gastrointestinal bleeding (OR 1.11, 95% CI 1.07-1.15, P < 0.001). Type 1 diabetes mellitus was shown to be a strong risk factor in PE patients for shock, right ventricular dysfunction, cardiopulmonary resuscitation and in-hospital death (OR 1.75, 95% CI 1.61-1.90, P < 0.001). CONCLUSIONS: Despite the progress in diabetes treatments, diabetes is still associated with an unfavorable clinical patient profile and higher risk for adverse events, including substantially increased in-hospital mortality in acute PE.

Geographic and Regional Variability in Racial and Ethnic Disparities in Stroke Thrombolysis in the United States.

BACKGROUND AND PURPOSE: Intravenous thrombolysis (IVT) after ischemic stroke is underutilized in racially/ethnically minoritized groups. We aimed to determine the regional and geographic variability in racial/ethnic IVT disparities in the United States. METHODS: Acute ischemic stroke admissions between 2012 and 2018 were identified in the National Inpatient Sample. Multivariable logistic regression was used to test the association between IVT and race/ethnicity, stratified by geographic region and controlling for demographic, clinical, and hospital characteristics. RESULTS: Of the 545 509 included cases, 47 031 (8.6%) received IVT. Racially/ethnically minoritized groups had significantly lower adjusted odds of IVT compared with White people in the South Atlantic region (odds ratio [OR], 0.86 [95% CI, 0.82-0.91]), the East North Central region (OR, 0.91 [95% CI, 0.85-0.97]) and the Pacific region (OR, 0.90 [95% CI, 0.85-0.96]). In the South Atlantic region, IVT use in racial/ethnic minority groups was below the national average of all racial/ethnic minority patients (P=0.002). Compared with White patients, Black patients had lower odds of IVT in the Middle Atlantic region (OR, 0.84 [95% CI, 0.78-0.91]), the South Atlantic region (OR, 0.78 [95% CI, 0.74-0.82]), and the East North Central region (OR, 0.86 [95% CI, 0.79-0.93]). In the South Atlantic region, this difference was below the national average for Black people (P<0.001). Hispanic patients had significantly lower use of IVT only in the Pacific region (OR, 0.92 [95% CI, 0.85-0.99]), while Asian/Pacific Islander patients had lower odds of IVT in the Mountain (OR, 0.76 [95% CI, 0.59-0.98]) and Pacific region (OR, 0.89 [95% CI, 0.82-0.97]). CONCLUSIONS: Racial/ethnic disparities in IVT use in the United States vary by region. Geographic hotspots of lower IVT use in racially/ethnically minoritized groups are the South Atlantic region, driven predominantly by lower use of IVT in Black patients, and the East North Central and Pacific regions.

Predictors of hemorrhagic complications after intravenous thrombolysis in acute cerebral infarction patients: A single-center study of 391 cases.

ABSTRACT: For patients with ischemic stroke, intravenous (IV) thrombolysis with Urokinase within 6 hours has been accepted as beneficial, but its application is limited by high risk of hemorrhagic complications after thrombolysis. This study aimed to analyze the risk factors of hemorrhagic complications after intravenous thrombolysis using Urokinase in acute cerebral infarction (ACI) patients.Total 391 consecutive ACI patients were enrolled and divided into 2 groups: the hemorrhagic complications group and the non-hemorrhagic complications group. The related data were collected and analyzed.Univariate analysis showed significant differences in prothrombin time, atrial fibrillation (AF), Mean platelet volume, large platelet ratio (L-PLR), triglyceride (TG), Lactate dehydrogenase, alanine aminotransferase (ALT), high-density lipoprotein, and baseline National Institute of Health Stroke Scale score between the hemorrhagic complications and the non-hemorrhagic complications group (P < .1). Multivariate logistic regression analysis indicated that AF (odds ratio [OR] = 2.91, 95% confidence interval [CI] = 1.06-7.99 P = .039) was the risk factor of hemorrhagic complications, while ALT (OR = 0.27, 95% CI = 0.10-0.72 P = .009) and TG (OR = 0.16, 95% CI = 0.06-0.45 P = .000) were protective factors of hemorrhagic complications.For patients with AF and lower levels of ALT or TG, the risk of hemorrhagic complications might increase after ACI.

Prognostic value of red blood cell distribution width in predicting 3-month functional outcome of patients undergoing thrombolysis treatment for acute ischemic stroke.

ABSTRACT: This study was performed to determine whether red blood cell distribution width (RDW) is associated with 3-month poor functional outcome in patients undergoing thrombolytic therapy for acute ischemic stroke.RDW was measured in patients with thrombolytic therapy in emergency department. Functional outcome was assessed after 3 months and poor functional outcome was defined as modified Rankin scale 3 to 6.A total of 240 patients were enrolled, and 82 (34.2%) had a poor functional outcome. The median RDW was significantly elevated in patients with a poor functional outcome compare with those with a good outcome. RDW was independently associated with a 3-month poor functional outcome (odds ratio 3.369, 95% confidence interval 2.214-5.125). The optimal RDW cutoff for predicting 3-month poor functional outcome was 12.8%, and the area under the curve for RDW was 0.818 (95% confidence interval 0.761-0.876). The area under the curve for RDW was higher in male patients than in female patients. The RDW correlated positively with the modified Rankin scale score after 3 months and the initial National Institutes of Health Stroke Scale score.Initial higher RDW level is related to a 3-month poor functional outcome in patients undergoing thrombolytic therapy for acute ischemic stroke.

The impact of COVID-19 pandemic in stroke code activation and time from symptom onset to hospital arrival in a Portuguese comprehensive stroke centre. / El impacto de la pandemia de COVID-19 en la activación del Código Ictus y en el tiempo desde el inicio de los síntomas hasta la llegada al hospital en un centro de ictus portugués.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) impacted emergency services worldwide. AIM: We aimed to evaluate COVID-19 effect on the number of stroke code activations and timings during the first two months of the pandemic. MATERIAL AND METHODS: We reviewed the stroke code database of a single comprehensive stroke centre in Portugal for the number of activations through 2019-2020. We compared the pathway timings between March and April 2020 (COVID-19 period) and the homologous months of the previous four years (pre-COVID-19 period), whilst using February as a control. RESULTS: Monthly stroke code activation rates decreased up to 34.2% during COVID-19 pandemic. Compared to the pre-COVID-19 period, we observed an increase in the time from symptom onset to emergency call, with a significant number of patients waiting more than four hours (March 20.8% vs. 6.8%, p = 0.034; April 23.8% vs. 6%, p = 0.01); as well as an increase in the time from symptom onset to hospital arrival (March: median 136 minutes [IQR 106-410] vs. 100 [IQR 64-175], p = 0.001; April: median 188 [IQR 96-394] vs. 98 [IQR 66-168], p = 0.007). No difference between both periods was found concerning in-hospital times, patient characteristics, stroke/mimic diagnosis, stroke severity, and mortality. CONCLUSION: COVID-19 related factors probably reduced healthcare services utilization, and delayed emergency calls and hospital arrival after stroke onset. These highlight the importance of health education to improve the effectiveness of medical assistance. The preservation of in-hospital times validates the feasibility of the protected stroke code protocol.

TITLE: El impacto de la pandemia de COVID-19 en la activación del Código Ictus y en el tiempo desde el inicio de los síntomas hasta la llegada al hospital en un centro de ictus portugués.Introducción. La enfermedad por coronavirus 2019 (COVID-19) provocó un considerable impacto mundial en los servicios de emergencia. Objetivo. Se pretende evaluar el efecto de la COVID-19 sobre el número y los tiempos de activaciones del Código Ictus en el comienzo de la pandemia. Material y métodos. Se revisó la base de datos del Código Ictus de un centro de ictus de Portugal entre 2016 y 2020. Se compararon los tiempos de activación entre marzo y abril de 2020 (período COVID-19) y los meses homólogos de los cuatro años anteriores, mientras que se utilizó febrero como control. Resultados. Las tasas mensuales de activación disminuyeron hasta el 34,2% durante la pandemia. En comparación con el período previo, se observó un aumento del tiempo desde los síntomas hasta la llamada de emergencia, con un aumento de pacientes que esperaron más de cuatro horas (marzo: 20,8 frente a 6,8%, p = 0,034; abril: 23,8 frente a 6%, p = 0,01) y del tiempo desde los síntomas hasta la llegada al hospital ­marzo: mediana de 136 minutos (rango intercuartílico [RIC]: 106-410) frente a 100 (RIC: 64-175), p = 0,001; abril: mediana de 188 (RIC: 96-394) frente a 98 (RIC: 66-168), p = 0,007­. No hubo diferencias en los tiempos de internamiento, las características de los pacientes, el diagnóstico de ictus/stroke mimics, la gravedad del ictus o la mortalidad. Conclusión. Los factores relacionados con la COVID-19 redujeron la utilización de los servicios sanitarios y retrasaron las llamadas de emergencia y el tiempo de llegada al hospital. Esto demuestra la importancia de la educación sanitaria para mejorar la eficacia de la asistencia médica.

An Original Risk Score to Predict Early Major Bleeding in Acute Pulmonary Embolism: The Syncope, Anemia, Renal Dysfunction (PE-SARD) Bleeding Score.

BACKGROUND: Improved prediction of the risk of early major bleeding in pulmonary embolism (PE) is needed to optimize acute management. RESEARCH QUESTION: Does a simple scoring system predict early major bleeding in acute PE patients, identifying patients with either high or low probability of early major bleeding? STUDY DESIGN AND METHODS: From a multicenter prospective registry including 2,754 patients, we performed post hoc multivariable logistic regression analysis to build a risk score to predict early (up to hospital discharge) major bleeding events. We validated the endpoint model internally, using bootstrapping in the derivation dataset by sampling with replacement for 500 iterations. Performances of this novel score were compared with that of the VTE-BLEED (Venous Thrombo-Embolism Bleed), RIETE (Registro informatizado de la enfermedad tromboembólica en España; Computerized Registry of Patients with Venous Thromboembolism), and BACS (Bleeding, Age, Cancer, and Syncope) models. RESULTS: Multivariable regression identified three predictors for the occurrence of 82 major bleeds (3.0%; 95% CI, 2.39%-3.72%): Syncope (+1.5); Anemia, defined as hemoglobin <12 g/dL (+2.5); and Renal Dysfunction, defined as glomerular filtration rate <60 mL/min (+1 point) (SARD). The PE-SARD bleeding score was calculated by summing all the components. Overall, 52.2% (95% CI, 50.29%-54.11%) of patients were classified as low bleeding-risk (score, 0 point), 35.2% (95% CI, 33.39%-37.04%) intermediate-risk (score, 1-2.5 points), and 12.6% (95% CI, 9.30%-16.56%) high-risk (score >2.5 points). Observed bleeding rates increased with increasing risk group, from 0.97% (95% CI, 0.53%-1.62%) in the low-risk to 8.93% (95% CI, 6.15%-12.44%) in the high-risk group. C-index was 0.74 (95% CI, 0.73-0.76) and Brier score 0.028 in the derivation cohort. Similar values were calculated from internal bootstrapping. Performance of the PE-SARD score was better than that observed with the VTE-BLEED, RIETE, and BACS scores, leading to a high proportion of bleeding-risk reclassification in patients who bled and those who did not. INTERPRETATION: The PE-SARD bleeding risk score is an original, user-friendly score to estimate risk of early major bleeding in patients with acute PE.

Case-fatality, disability and recurrence rates after first-ever stroke: A study from bigdata observatory platform for stroke of China.

BACKGROUND: There is currently a lack of data on stroke hospitalizations and long-term outcomes in China. Therefore, we investigated 12-month stroke fatality, disability, and recurrence rates after the first-ever stroke. METHODS: This was a prospective nationwide hospital-based cohort study. From August to September 2019, all patients with first-ever stroke (ischemic stroke [IS], intracerebral hemorrhage [ICH], and subarachnoid hemorrhage [SAH]) and with symptom onset within 14 days from 232 hospitals were included. Case fatality, disability, and recurrence rates for one year were estimated. RESULTS: In total, 36250 first-ever stroke patients from 194 hospitals were recruited (median age was 65(IQR, 56-73) years and 61.4 % were male). The rate of intravenous thrombolysis and endovascular treatment for IS were 9.5 % and 4.4 %, respectively. In-hospital death rate was 1.9 % (95 %CI: 1.7 %-2.0 %) for stroke inpatients, ranging from 0.9 % (0.8 %-1.1 %) for IS to 5.1 % (4.6 %-5.6 %) for ICH. The 12-month fatality rate was 8.6 % (95 %CI: 8.3 %-8.9 %) for discharged stroke patients, ranging from 6.0 % (5.7 %-6.3 %) for IS to 17.7 % (16.7 %-18.7 %) for ICH. The 12-month disability rate was 16.6 % (95 %CI: 16.2 %-17.0 %) for stroke survivors, ranging from 11.1 % (9.3 %-12.8 %) for SAH to 29.2 % (27.9 %-30.4 %) for ICH. The stroke recurrence rate was 5.7 % (5.5 %-6.0 %) for stroke survivors, ranging from 2.5 % (1.7 %-3.3 %) for SAH to 6.4 % (6.0 %-6.7 %) for IS. CONCLUSION: Our results support the hypothesis that the prognosis of Chinese stroke patients appears to have improved and is not very bad.

Clinical Risk Factors Associated with Ambulatory Outcome in Acute Ischemic Stroke Patient Smokers Treated with Thrombolytic Therapy.

BACKGROUND: Patients who have suffered an acute ischemic stroke (AIS) and are smokers may have a better outcome following thrombolytic therapy when compared with non-smokers. While this finding is controversial, data on baseline clinical risk factors to predict treatment efficacy of thrombolytic therapy using ambulatory status in patients who suffered AIS and are smokers is not common. METHODS: Between 2010 and 2016, retrospective data on patients who have suffered an AIS and received recombinant tissue plasminogen activator (rtPA) were obtained from Greenville health system registry. Assessment of clinical risk factors and the likelihood of an improvement in post-stroke ambulation among smokers and non-smokers was carried out using multivariate logistic regression. RESULTS: Of 1001 patients, 70.8% were smokers and 29.2% non-smokers. Among the smokers and non-smokers, 74.6% and 84.6% improvement in ambulation respectively at discharge. The odds of improved ambulation decrease among smokers as age group increases compared to those below 50 [(60-69 years, aOR, 0.30, 95% C.I, 0.108-0.850, p < 0.05), (70-79 years aOR, 0.27, 95% C.I, 0.096-0.734, p < 0.05), (80+ years aOR, 0.16, 95% C.I, 0.057-0.430, P < 0.01). Patients with National Institute of Health Stroke Scale Score (NIHSS) score > 7 (reference <7) were 91% less likely to have improved ambulation among smokers and non-smokers (aOR, 0.09, 95% C.I, 0.055-0.155, P = 0.01), and (aOR, 0.08, 95% C.I, 0.027-0.214, P = 0.01) respectively. Atrial fibrillation was an independent predictor of decreased improvement in ambulation only among smokers (aOR, 0.58, 95% C.I, 0.356-0.928 P < 0.05). CONCLUSION: Our findings suggest that elderly smokers with atrial fibrillation would benefit more from aggressive management of atrial fibrillation than non-smokers.

Carotid Endarterectomy Following Intravenous Thrombolysis in the UK.

OBJECTIVE: The aim of this study was to evaluate the effect of pre-operative intravenous thrombolytic therapy (ivTT) on short term outcomes after carotid endarterectomy (CEA) among patients who presented with ischaemic stroke. METHODS: A retrospective study using a large population based dataset from the National Vascular Registry in the United Kingdom (UK-NVR). The cohort included adult patients who underwent CEA for ischaemic stroke between 1 January 2014 and 31 December 2019. NVR records provided information on patient demographics, Rankin score, medication, time from onset of symptoms to surgery and whether the patient received ivTT prior to surgery. Logistic regression was used to evaluate the relationship between ivTT and rates of any stroke at 30 days after CEA and in hospital complication rates for neck haematoma. Secondary outcomes included in hospital cardiac and respiratory complications, and cranial nerve injury. RESULTS: Between 2014 and 2019, 9 030 patients presented with a stroke and underwent CEA, of whom 1 055 (11.7%) had received pre-operative ivTT. Those receiving ivTT were younger (mean 70.6 vs. 72.0 years, p < .001). The median (IQR) time from symptom to CEA was 10 days (6 - 17) for ivTT patients and 11 days (7 - 20) for CEA patients not receiving ivTT. Post-operative rates of 30 day stroke were similar between the no ivTT (2.1%) and ivTT (1.8%) cohorts (p = .48). In hospital neck haematomas were statistically significantly more common in CEA patients receiving ivTT (3.7%) vs. no ivTT (2.3%) (p = .006). There was no statistically significant association between 30 day stroke and neck haematoma complications when stratified for delays from symptom onset to CEA, but the overall cohort contained few adverse events for analysis during the very early time period. CONCLUSION: The use of ivTT before CEA in stroke patients was not associated with an increased risk of 30 day stroke, but there was an increase in the risk of neck haematoma.

Safety and Outcomes of Thrombectomy in Ischemic Stroke With vs Without IV Thrombolysis.

OBJECTIVE: To test the hypothesis that IV thrombolysis (IVT) treatment before endovascular thrombectomy (EVT) is associated with better outcomes in patients with anterior circulation large artery occlusion (LAO) stroke, we examined a large real-world database, the Safe Implementation of Treatment in Stroke-International Stroke Thrombectomy Register (SITS-ISTR). METHODS: We identified centers recording ≥10 consecutive patients in the SITS-ISTR, with at least 70% available modified Rankin Scale (mRS) scores at 3 months during 2014 to 2019. We defined LAO as intracranial internal carotid artery, first and second segment of middle cerebral artery, and first segment of anterior cerebral artery. Main outcomes were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial hemorrhage (SICH) per modified SITS-Monitoring Study. We performed propensity score-matched (PSM) and multivariable logistic regression analyses. RESULTS: Of 6,350 patients from 42 centers, 3,944 (62.1%) received IVT. IVT + EVT-treated patients had less frequent atrial fibrillation, ongoing anticoagulation, previous stroke, heart failure, and prestroke disability. PSM analysis showed that IVT + EVT-treated patients had a higher rate of functional independence than patients treated with EVT alone (46.4% vs 40.3%, p < 0.001) and a lower rate of death at 3 months (20.3% vs 23.3%, p = 0.035). SICH rates (3.5% vs 3.0%, p = 0.42) were similar in both groups. Multivariate adjustment yielded results consistent with PSM. CONCLUSION: Pretreatment with IVT was associated with favorable outcomes in EVT-treated LAO stroke in the SITS-ISTR. These findings, while indicative of international routine clinical practice, are limited by observational design, unmeasured confounding, and possible residual confounding by indication. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that IVT before EVT increases the probability of functional independence at 3 months compared to EVT alone.

Sex Differences in Stroke Care and Outcome 2005-2018: Observations From the Swedish Stroke Register.

Background and Purpose: Previous studies of stroke management and outcome in Sweden have revealed differences between men and women. We aimed to analyze if differences in stroke incidence, care, and outcome have altered over time. Methods: All stroke events registered in the Swedish Stroke Register 2005 to 2018 were included. Background variables and treatment were collected during the acute hospital stay. Survival data were obtained from the national cause of death register by individual linkage. We used unadjusted proportions and estimated age-adjusted marginal means, using a generalized linear model, to present outcome. Results: We identified 335 183 stroke events and a decreasing incidence in men and women 2005 to 2018. Men were on average younger than women (73.3 versus 78.1 years) at stroke onset. The age-adjusted proportion of reperfusion therapy 2005 to 2018 increased more rapidly in women than in men (2.3%­15.1% in men versus 1.4%­16.9% in women), but in 2018, women still had a lower probability of receiving thrombolysis within 30 minutes. Among patients with atrial fibrillation, oral anticoagulants at discharge increased more rapidly in women (31.2%­78.6% in men versus 26.7%­81.9% in women). Statins remained higher in men (36.9%­83.7% in men versus 32.3%­81.2% in women). Men had better functional outcome and survival after stroke. After adjustment for women's higher age, more severe strokes, and background characteristics, the absolute difference in functional outcome was <1% and survival did not differ. Conclusions: Stroke incidence, care, and outcome show continuous improvements in Sweden, and previously reported differences between men and women become less evident. More severe strokes and older age in women at stroke onset are explanations to persisting differences.

Risks and benefits of percutaneous coronary intervention in spontaneous coronary artery dissection.

OBJECTIVE: To investigate percutaneous coronary intervention (PCI) practice in an international cohort of patients with spontaneous coronary artery dissection (SCAD). To explore factors associated with complications and study angiographic and longer term outcomes. METHODS: SCAD patients (n=215, 94% female) who underwent PCI from three national cohort studies were investigated and compared with a matched cohort of conservatively managed SCAD patients (n=221). RESULTS: SCAD-PCI patients were high risk at presentation with only 8.8% undergoing PCI outside the context of ST-elevation myocardial infarction/cardiac arrest, thrombolysis in myocardial infarction (TIMI) 0/1 flow or proximal dissections. PCI complications occurred in 38.6% (83/215), with 13.0% (28/215) serious complications. PCI-related complications were associated with more extensive dissections (multiple vs single American Heart Association coronary segments, OR 1.9 (95% CI: 1.06-3.39),p=0.030), more proximal dissections (proximal diameter per mm, OR 2.25 (1.38-3.67), p=0.001) and dissections with no contrast penetration of the false lumen (Yip-Saw 2 versus 1, OR 2.89 (1.12-7.43), p=0.028). SCAD-PCI involved long lengths of stent (median 46mm, IQR: 29-61mm). Despite these risks, SCAD-PCI led to angiographic improvements in those with reduced TIMI flow in 84.3% (118/140). Worsening TIMI flow was only seen in 7.0% (15/215) of SCAD-PCI patients. Post-PCI major adverse cardiovascular and cerebrovascular events (MACCE) and left ventricular function outcomes were favourable. CONCLUSION: While a conservative approach to revascularisation is favoured, SCAD cases with higher risk presentations may require PCI. SCAD-PCI is associated with longer stent lengths and a higher risk of complications but leads to overall improvements in coronary flow and good medium-term outcomes in patients.

Impact of COVID-19 on the rate of stroke cases at a tertiary hospital in Makkah, Saudi Arabia.

OBJECTIVES: To assess and quantify the impact COVID-19 has had thus far on ischemic stroke admission rate and severity (National Institutes of Health Stroke Scale (NIHSS) score) at a single tertiary center in Makkah, Saudi Arabia. METHODS: This is a retrospective analysis performed on admitted cases with definitive final diagnoses of transient ischemic attack (TIA) and ischemic stroke at King Abdullah Medical City in Makkah between January 1, 2020 and July 2020. RESULTS: Sixty-nine patients were included in our study, 41 of whom presented at our facility before the pandemic and 29 during the pandemic. No statistical significance was observed between rate of admission, stroke severity, and rate of thrombolysis before the COVID-19 pandemic and after the outbreak. We observed a reduction of mean arrival time after the pandemic began, as well as a reduction of hospital stay days. CONCLUSION: A 29% reduction of admission secondary to acute ischemic stroke was noted during the pandemic. However, COVID-19 did not affect acute stroke care at our institute. The study is limited because of its small sample size, as we assessed just one medical center.

Effect of the COVID-19 pandemic and the lockdown measures on the local stroke network.

INTRODUCTION: The COVID-19 outbreak highly impacted the acute ischemic stroke care management. The primary end point of the study was to evaluate the impact of the COVID-19 outbreak and the following lockdown measures on our hub-and-spoke network; the secondary end point was to evaluate if the impact of the COVID-19 outbreak was different in hub-and-spoke centers. METHODS: This was a retrospective multicenter observational study conducted at the Stroke Units of Policlinico Gemelli, Ospedale San Filippo Neri, Ospedale di Belcolle, and Ospedale San Camillo de Lellis. We collected clinical reports of all consecutive patients admitted with diagnosis of acute ischemic stroke or transient ischemic attack (TIA) during the phase 1 of the lockdown period (11 March 2020-4 May 2020). As controls, we used all consecutive patients admitted for acute ischemic stroke or TIA in the same period of the previous year. RESULTS: A total of 156 and 142 clinical reports were collected in 2019 and 2020, respectively. During the COVID-19 outbreak, we observed a reduction of number of thrombolysis, a reduction of the length of hospitalization, and an increase of pneumonia. Regarding performance indicators, we observed an increase in onset-to-door time and in door-to-groin time. We did not observe any statistically significant interaction between year (2019 vs 2020) and facility of admission (hub vs spoke) on all variables analyzed. DISCUSSION: Our observational study, involving hub-and-spoke stroke network of a wide regional area, indicates that the COVID-19 outbreak impacted on the acute stroke management. This impact was equally observed in hub as well as in spoke centers.