Carlos Corado

Impact of Poststroke Medical Complications on 30-Day Readmission Rate

BACKGROUND Some previously identified predictors of 30-day stroke readmission, including age and stroke severity, are nonmodifiable. We assessed the hypothesis that in-hospital medical complications, which are potentially modifiable, after ischemic stroke (IS) and transient ischemic attack (TIA) predict 30-day readmission. METHODS In a single-center prospective cohort study of IS and TIA patients admitted from August 1, 2012, to July 31, 2013, we identified those who survived to 30-day follow-up or died during a readmission within 30 days. Patients readmitted within 30 days of discharge were identified by telephone assessment and review of hospital records. We evaluated the association between 12 prespecified and prospectively collected poststroke medical complications and 30-day readmission adjusting for baseline characteristics, in-hospital course and treatments, and discharge status using univariable and multivariable Cox proportional hazards models. RESULTS Among 505 patients, 107 (21.2%) patients had at least 1 medical complication during hospitalization. The most common complications were urinary tract infection (8.7%), venous thromboembolism (6.1%), and pneumonia (4.6%). Seventy-eight (15.4%) patients were readmitted within 30 days. On multivariable Cox proportional hazards analysis, cardioembolic or large-artery atherosclerotic subtype (adjusted hazard ratio [HR], 1.82; 95% confidence interval [CI], 1.17-2.83) and any medical complication (adjusted HR, 1.68; 95% CI, 1.04-2.73) increased the risk of 30-day readmission. Among the 24 readmitted patients who experienced an initial medical complication, 10 (41.6%) were considered potentially preventable. CONCLUSIONS The occurrence of medical complications after IS or TIA increased the risk of 30-day all-cause readmission. Stroke patients with medical complications may be suitable for targeted interventions to prevent readmissions.

Quality of life in patients with TIA and minor ischemic stroke.

Objective: We investigated health-related quality of life (HRQOL) in patients with TIA and minor ischemic stroke (MIS) using Neuro-QOL, a validated, patient-reported outcome measurement system. Methods: Consecutive patients with TIA or MIS who had (1) modified Rankin Scale (mRS) score of 0 or 1 at baseline, (2) initial NIH Stroke Scale score of ≤5, (3) no acute reperfusion treatment, and (4) 3-month follow-up, were recruited. Recurrent stroke, disability by mRS and Barthel Index, and Neuro-QOL scores in 5 prespecified domains were prospectively recorded. We assessed the proportion of patients with impaired HRQOL, defined as T scores more than 0.5 SD worse than the general population average, and identified predictors of impaired HRQOL using logistic regression. Results: Among 332 patients who met study criteria (mean age 65.7 years, 52.4% male), 47 (14.2%) had recurrent stroke within 90 days and 41 (12.3%) were disabled (mRS >1 or Barthel Index <95) at 3 months. Any HRQOL impairment was noted in 119 patients (35.8%). In multivariate analysis, age (adjusted odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01–1.04), initial NIH Stroke Scale score (adjusted OR 1.39, 95% CI 1.17–1.64), recurrent stroke (adjusted OR 2.10, 95% CI 1.06–4.13), and proxy reporting (adjusted OR 3.94, 95% CI 1.54–10.10) were independent predictors of impaired HRQOL at 3 months. Conclusions: Impairment in HRQOL is common at 3 months after MIS and TIA. Predictors of impaired HRQOL include age, index stroke severity, and recurrent stroke. Future studies should include HRQOL measures in outcome assessment, as these may be more sensitive to mild deficits than traditional disability scales.

Challenges in the Medical Management of Symptomatic Intracranial Stenosis in an Urban Setting

Background and Purpose— Since the SAMMPRIS trial (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis), aggressive medical management (AMM), which includes dual antiplatelet therapy (DAPT) and high-dose statin (HDS) therapy, is recommended for patients with symptomatic intracranial atherosclerotic disease. However, limited data on the real-world application of this regimen exist. We hypothesized that recurrent stroke risk among patients treated with AMM is similar to the medical arm of the SAMMPRIS cohort. Methods— Using a prospective registry, we identified all patients admitted between August 2012 and March 2015 with (1) confirmed ischemic stroke or transient ischemic attack; (2) independently adjudicated symptomatic intracranial atherosclerotic disease; and (3) follow-up at 30 days. We analyzed 30-day risk of recurrent ischemic stroke stratified by treatment: (1) AMM: DAPT plus HDS therapy, (2) HDS alone, and (3) DAPT alone. We also assessed 30-day risk among patients who met prespecified SAMMPRIS eligibility criteria. Results— Among 99 patients who met study criteria (51.5% male, 54.5% black, mean age 68.2±11.2 years), 49 (48.5%) patients were treated with AMM, 69 (69.7%) with DAPT, and 73 (73.7%) with HDS therapy. At 30 days, 20 (20.2%) patients had recurrent strokes in the territory of stenosis. Compared with the risk in the medical arm of SAMMPRIS (4.4%), the 30-day risk of recurrent stroke was 20.4% in AMM patients, 21.5% in HDS patients, 22.4% in DAPT patients, and 23.2% in SAMMPRIS-eligible patients (all P<0.001). Conclusions— Recurrent stroke risk within 30 days in patients with symptomatic intracranial atherosclerotic disease was higher than that observed in the medical arm of SAMMPRIS even in the subgroup receiving AMM. Replication of the SAMMPRIS findings requires further prospective study.

Predicting Domain-Specific Health-Related Quality of Life Using Acute Infarct Volume

Background and Purpose— Limited data exist on the relationship between acute infarct volume and health-related quality of life (HRQOL) measures after ischemic stroke. We evaluated whether acute infarct volume predicts domain-specific Neuro-Quality of Life scores at 3 months after stroke. Methods— Between 2012 and 2014, we prospectively enrolled consecutive patients with ischemic stroke and calculated infarct volume. Outcome scores at 3 months included modified Rankin Scale and Neuro-Quality of Life T scores. We evaluated whether volume organized by quartiles predicted modified Rankin Scale and HRQOL scores at 3 months using logistic and linear regression as appropriate, adjusting for relevant covariates. We calculated variance accounted for (R2) overall and by volume for each domain of HRQOL. Results— Among 490 patients (mean age 64.2±15.86 years; 51.2% male; 63.3% White) included for analysis, 58 (11.8%) were disabled (modified Rankin Scale score of >2) at 3 months. In unadjusted analysis, the highest volume quartile remained a significant predictor of 1 HRQOL domain, applied cognition–general concerns (R2=0.06; P<0.001). Our fully adjusted prediction model explained 32% to 51% of the variance in HRQOL: upper extremity (R2=0.32), lower extremity (R2=0.51), executive function (R2=0.45), and general concerns (R2=0.34). Conclusions— Acute infarct volume is a poor predictor of HRQOL domains after ischemic stroke, with the exception of the cognitive domain. Overall, clinical and imaging variables explained <50% of the variance in HRQOL outcomes at 3 months. Our data imply that a broad range of factors, some known and others undiscovered, may better predict poststroke HRQOL than what is currently available.

Infarct location is associated with quality of life after mild ischemic stroke

Background In patients with mild ischemic stroke, small but eloquent infarcts may have devastating effects, particularly on health-related quality of life. Aim This study investigates the association between acute infarct location and three-month health-related quality of life in patients with mild ischemic stroke. Methods We evaluated consecutively enrolled patients from a single center between August 2012 and July 2013. Our primary outcome at three months was impairment in any health-related quality of life domain (upper extremity, lower extremity, executive function, and general concerns) defined by a T-score <45. We analyzed the association between acute infarct locations and impaired health-related quality of life at three months in univariate and multivariable analysis. Results Among 229 patients (mean age 64.9 years, 55% male, 29.7% black, and median initial NIHSS score 1), impaired health-related quality of life was noted in 84 (36.2%) patients at three months. In univariate analysis, patients with subcortical infarcts (56.0% vs. 39.3%, p = 0.02) and brainstem infarcts (21.4% vs. 10.3%, p = 0.02) were more likely to have impaired health-related quality of life. In multivariable analysis, patients with subcortical and/or brainstem infarcts had increased odds of impaired health-related quality of life (adjusted OR 2.54, 95% CI 1.29–5.01, p = 0.01). Conclusions After mild ischemic stroke, subcortical and brainstem infarct locations predict impairment in health-related quality of life.

Reduced Functional and Quality of Life Outcomes Associated With Delays in Evaluation for Acute Rehabilitation Services

Objective(s): To assess the impact of delays in evaluation for rehabilitation services on disability and health-related quality of life (HRQoL) after ischemic stroke and transient ischemic attack (TIA). Design: Rehabilitation evaluations (i.e., PT: physical therapy; OT: occupational therapy) were obtained from a retrospective chart review and HRQoL measures from a longitudinal observational study of poststroke outcomes. Setting: Stroke Center provided rehabilitation-related data. Participants in the community provided HRQoL data. Participants: Individuals post-stroke (nZ420) who underwent physical or occupational therapy evaluations. The sample was on average 66.2 years old (SDZ15.7), was largely white (64.1%); 47.4% were female, and 13.3% had a TIA diagnosis. Interventions: Usual rehabilitation services. Main Outcome Measure(s): Modified Rankin Scale (mRS) at 1 and 3months post-stroke and Neurological Quality of Life (NeuroQoL) measures of upperand lower-extremity physical function, general cognitive concerns, and executive function. Results: The mean number of days between hospital admission to evaluation (i.e., delay) was 3.2 (SDZ2.9) for PT and 4.4 (SDZ4.5) for OT. After controlling for age, stroke severity and stroke subtype, each additional day of delay resulted in higher levels of disability (mRS: PT, bZ0.06, p<0.01; OT, bZ0.08, p<0.001) and additional decrements in physical function (Upper Extremity: OT, bZ-0.37, p<0.01; Lower Extremity: PT, bZ-0.47, p<0.05; OT, bZ-0.57, p<0.001) and cognitive function (Executive Function: PT, bZ-0.65, p<0.01; OT: bZ-0.84, p<0.001; General Concerns: PT, bZ-0.54, p<0.01; OT, bZ-0.47, p<0.001) at 1-month post-stroke. All effects were maintained at 3-months for OT only. Conclusions: Long-term disability after stroke is associated with delayed evaluation for rehabilitation services. In order to reduce long-term disability, early evaluation should be implemented, but the appropriate timing to initiate rehabilitation post-stroke is still unknown.