Afshin A. Divani

Changes in Cost and Outcome Among US Patients With Stroke Hospitalized in 1990 to 1991 and Those Hospitalized in 2000 to 2001

Background and Purpose— The purpose of this study was to evaluate the impact of new treatments by examining the changes between 1990 to 1991 and 2000 to 2001 in in-hospital mortality rates and hospital charges in adult patients with stroke. Methods— From the Nationwide Inpatient Survey, the largest all-payer inpatient care database in the United States, patients with stroke admitted in 1990 to 1991 or 2000 to 2001 were studied. We analyzed hospital charges (adjusted for inflation based on the Consumer Price Index of the Bureau of Labor Statistics) and patient outcomes by type of institution: rural, urban nonteaching, and urban teaching in 1990 to 1991 and in 2000 to 2001. Results— In 1990 to 1991, there were 1 736 352 admissions for cerebrovascular diseases, and in 2000 to 2001, there were 1 958 018 admissions. The number of admissions in urban teaching hospitals increased by 13%, 19%, and 25%, for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, respectively. The overall in-hospital mortality rate relatively declined by 36% for ischemic stroke, by 6% for intracerebral hemorrhages, and by 10% for subarachnoid hemorrhage. The mean hospital charges increased from

Thrombolysis for ischemic stroke in the United States: data from National Hospital Discharge Survey 1999-2001.

10 500 to

Intra-arterial reteplase and intravenous abciximab in patients with acute ischemic stroke: An open-label, dose-ranging, phase I study

16 200 for patients with ischemic stroke, from

Carotid angioplasty with or without stent placement versus carotid endarterectomy for treatment of carotid stenosis : A meta-analysis

18 300 to

Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines.

28 800 for patients with intracerebral hemorrhage, and from

Trends in hospitalization and mortality for subarachnoid hemorrhage and unruptured aneurysms in the United States

37 400 to

Risk factors associated with injury attributable to falling among elderly population with history of stroke

65 900 for patients with subarachnoid hemorrhage. Mortality rates among patients admitted after ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage were all lower in urban teaching hospitals than in rural and urban nonteaching hospitals and the mean charges per admission were all higher. Conclusions— There has been an increase in the inflation-adjusted hospital charges for all patients with stroke and a reduction in mortality rates for all stroke subtypes probably related to an increase in the proportion of patients with stroke admitted to urban teaching hospitals.

Is IV tissue plasminogen activator beneficial in patients with hyperdense artery sign

OBJECTIVE:Although some data regarding the use of thrombolysis are available from community-based studies, national estimates of the use of thrombolysis for ischemic stroke are not available. We performed this study to determine the frequency of thrombolysis for ischemic stroke in the United States and associated in-hospital outcomes. METHODS:National estimates of thrombolysis, associated in-hospital outcomes, and mortality were obtained from National Hospital Discharge Survey data from 1999 to 2001. Patient numbers and frequency distributions were calculated for a nationally representative sample of patients hospitalized with a primary diagnosis of ischemic stroke. Thrombolysis was further stratified into thrombolysis with (intra-arterial) or without (intravenous) cerebral angiography. RESULTS:There were 1,796,513 admissions for ischemic stroke between 1999 and 2001. Of these admitted patients, 1,314 (0.07%) underwent intra-arterial thrombolysis and 11,283 (0.6%) underwent intravenous thrombolysis. The days of hospitalization (mean ± standard deviation) were significantly higher for patients admitted with ischemic stroke treated with intra-arterial thrombolysis (10.7 ± 4.8) or intravenous thrombolysis (7.1 ± 3.6) compared with non-thrombolytic admissions (5.4 ± 5.7). We observed a trend toward a higher frequency of use of intravenous and intra-arterial thrombolysis and hospitals with greater number of beds (P < 0.01). The mortality rates for hospitalizations were not significantly different for admissions with ischemic stroke treated with intra-arterial or intravenous thrombolysis compared with other ischemic strokes. The rates of discharge to home after hospitalizations were significantly lower for patients treated with intravenous thrombolysis (19.8%) compared with those not treated with thrombolysis (53.1%). CONCLUSION:The present study provides national estimates of patients undergoing thrombolysis for ischemic stroke. Further efforts need to be made to increase the proportion of patients with ischemic stroke who receive thrombolysis in the United States.

Intracranial Aneurysms: Review of Current Treatment Options and Outcomes

OBJECTIVE:New approaches are focusing on using a combination of medication that lyse fibrin and prevent aggregation of platelets to achieve higher rates of recanalization and improved clinical outcomes. METHODS:A prospective, nonrandomized, open-label trial evaluated the safety of an escalating dose of reteplase in conjunction with intravenous abciximab (platelet glycoprotein IIb/IIIa inhibitor) in patients with acute ischemic stroke (3–6 h after symptom onset). The primary endpoint was symptomatic intracerebral hemorrhage at 24 to 72 hours, and secondary endpoints were partial or complete recanalization (≥ one grade improvement), early neurological improvement (decrease in National Institutes of Health Stroke Scale ≥ 4 at 24 h), and favorable outcome at 1 month (defined by modified Rankin scale ≤ 2). RESULTS:A total of 20 patients (mean age, 65 yr; 13 men) were recruited. Five patients were recruited in each of the escalating tiers of intra-arterial reteplase (0.5, 1, 1.5, and 2 units). Intravenous abciximab (0.25 mg/kg bolus followed by 0.125 &mgr;g/kg/min) was successfully administered in 18 out of 20 patients. The safety stopping rule was not activated in any of the tiers. One symptomatic intracerebral hemorrhage was observed in one of the 20 patients (in the 1-unit tier). Partial or complete recanalization was observed in 13 of the 20 patients. Thirteen patients demonstrated early neurological improvement, and favorable outcome at 1 month was observed in six patients. CONCLUSION:In this study, a combination of intra-arterial reteplase and intravenous abciximab was safely administered to patients with ischemic stroke presenting between 3 and 6 hours after symptom onset.

Cigarette smoking among spouses: another risk factor for stroke in women.

OBJECTIVE: Carotid angioplasty with or without stent placement (CAS) has been proposed as an alternative method to carotid endarterectomy (CEA) for treatment of carotid stenosis. Small randomized trials have evaluated the comparative efficacy of both methods; however, definitive evidence is lacking. METHODS: A search was made for randomized clinical trials comparing CAS and CEA for treatment of carotid stenosis. A literature search of MEDLINE, PubMed, and Cochrane databases was supplemented by a review of bibliographies of relevant articles and personal files. A meta-analysis was performed using a random effects model because significant heterogeneity was observed. Outcomes compared included 1-month composite rates of stroke or death, all strokes, disabling strokes, myocardial infarction, cranial nerve injury, and major bleeding and 1-year rates of both minor and major ipsilateral strokes. RESULTS: We analyzed five randomized trials totaling 1154 patients (577 randomized to CEA and 577 randomized to CAS). The composite end point of 1-month stroke or death rate was not different between patients treated with CAS compared with those treated with CEA (relative risk [RR], 1.3; 95% confidence interval [CI], 0.6–2.8; P = 0.5). The 1-month stroke rate (831 patients analyzed: RR, 1.3; 95% CI, 0.4–3.6; P = 0.7) and disabling stroke rate (831 patients analyzed: RR, 0.9; 95% CI, 0.2–3.5; P = 0.9) was similar for CAS and CEA. The 1-month rates of myocardial infarction (814 patients analyzed: RR, 0.3; 95% CI, 0.1–0.9) and cranial nerve injury (918 patients analyzed: RR, 0.05; 95% CI, 0.01–0.3) were significantly lower for CAS. No significant differences were observed in 1-year rates of ipsilateral stroke (814 patients analyzed: RR, 0.8; 95% CI, 0.5–1.2; P = 0.2). CONCLUSION: The 30-day stroke and death rates associated with CAS and CEA were not significantly different. Lower rates of myocardial infarction and cranial nerve injury were observed with CAS compared with CEA.