Gabriel Vidal

Acute Renal Failure Is Associated With Higher Death and Disability in Patients With Acute Ischemic Stroke Analysis of Nationwide Inpatient Sample

Background and Purpose— Acute renal failure (ARF) in setting of acute ischemic stroke (AIS) is associated with worse outcome. We sought to determine the prevalence of ARF and effect on outcomes of patients with AIS. Methods— Data from all patients admitted to US hospitals between 2002 and 2010 with a primary discharge diagnosis of ischemic stroke and secondary diagnosis of ARF were included. The effect of ARF on rates of intracerebral hemorrhage and discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. Results— Of 7 068 334 patients with AIS, 372 223 (5.3%) had ARF during hospitalization. Dialysis was required in 2364 (0.6%) of 372 223 patients. Patients with AIS with ARF had higher rates of moderate to severe disability (41.3% versus 30%; P<0.0001), intracerebral hemorrhage (1.0% versus 0.5%; P<0.0001), and in-hospital mortality (8.4% versus 2.9%; P<0.0001) compared with those without ARF. After adjusting for confounding factors, patients with AIS with ARF had higher odds of moderate to severe disability (odds ratio, 1.3; 95% confidence interval, 1.3–1.4; P<0.0001), intracerebral hemorrhage (odds ratio, 1.4; 95% confidence interval, 1.3–1.6; P<0.0001), and death (odds ratio, 2.2; 95% confidence interval, 2.0–2.2; P<0.0001). Conclusions— ARF in patients with AIS is associated with significantly higher rates of moderate to severe disability at discharge and in-hospital mortality.

Urgent carotid intervention is safe after thrombolysis for minor to moderate acute ischemic stroke

OBJECTIVE Carotid intervention shortly after an acute neurologic ischemic event is being performed more frequently in stroke centers to reduce the risk of recurrent stroke. Thrombolysis with recombinant tissue plasminogen activator (tPA) is offered to select patients with ischemic stroke symptoms who present within 4.5 hours. However, there is a paucity of data as to whether tPA followed by urgent carotid endarterectomy (CEA) or carotid artery stenting (CAS) has an increased risk of complications, particularly intracerebral hemorrhage (ICH). We sought to determine the periprocedural complications of urgently performed CEA or CAS following tPA. METHODS From January 2009 to January 2015, 762 patients underwent carotid interventions (CEA, n = 440; CAS, n = 322) at a tertiary referral center and 165 patients (21.6%) underwent an urgent CEA or CAS during the index hospitalization for an acute transient ischemic attack or stroke. We compared the effect of intravenous tPA on 30-day complications, including ICH. The χ(2) and Fisher exact tests were used to determine significance between groups. RESULTS During the 6-year period, 165 patients underwent urgent carotid interventions (CEA, n = 135; CAS, n = 30) for acute neurologic symptoms. Of these, 19% (31 patients [CEA, n = 25; CAS, n = 6]) had tPA for an acute stroke; the remaining (134 patients [CEA, n = 110; CAS, n = 24]) fell outside of the tPA time window. Most strokes were minor or moderate with a mean National Institutes of Health Stroke Scale (NIHSS) score of 6.6 (range, 0-19). The mean time to intervention for both groups was 2.4 days (0-15 days). The 30-day stroke, death, and myocardial infarction rates were 9.7% (3 of 31) for the tPA group compared with 4.5% (6 of 134) for the no-tPA group (P = .37). Including bleeding complications in these 30-day outcomes, there was no difference between the tPA (3 of 31) and the no-tPA cohorts (8 of 134; P = .43). In the tPA group, there were one ICH, one neck hematoma/death, and an additional death; in the no-tPA group, there were one ICH, two neck hematomas, one stroke, two myocardial infarctions, one ICH/death, and one additional death. No significant increased rates of bleeding were noted within the tPA group (2 of 31) compared with the no-tPA group (4 of 134; P = .32). Moreover, in the tPA cohort, more than half of the patients (17 of 31) underwent revascularization within 72 hours (CEA = 13; CAS = 4) with outcomes similar to those who underwent revascularization after 72 hours. CONCLUSIONS Thrombolysis followed by urgent CEA or CAS is not associated with an increased risk of complications in select patients who present with acute neurologic symptoms. Selection of patients is important; there was no ICH and only one death in each group for patients with minor to moderate ischemic stroke (NIHSS score <10).

A stroke/vascular neurology service increases the volume of urgent carotid endarterectomies performed in a tertiary referral center.

BACKGROUND Increasing evidence supports that urgent carotid endarterectomy (CEA), defined as CEA during the index hospitalization, may be undertaken in select patients with acute carotid-related neurologic symptoms to prevent recurrent ischemic events. We aimed to determine the effect of a stroke/vascular neurology service on the volume of urgent CEAs performed and assess perioperative outcomes. METHODS A retrospective review from a single tertiary referral center between June 2005 through December 2011 revealed 393 patients who underwent CEA. We identified the number of urgent CEAs before (June 2005-August 2008) and after (September 2008-December 2011) a stroke/vascular neurology service was implemented, as well as asymptomatic CEAs and symptomatic but electively performed CEAs. Demographic data as well as 30-day adverse outcomes (transient ischemic attack [TIA], stroke, myocardial infarction, and mortality) were analyzed for each group. In patients undergoing urgent CEA, TIA and stroke severity were assessed by a stroke neurologist using the ABCD2 TIA score and National Institutes of Health Stroke Scale (NIHSS), respectively. The χ2 test was used to compare differences between the urgent CEA volume before and after a stroke/vascular neurology service. Fishers exact test was used to analyze perioperative outcomes. RESULTS Demographics and comorbidities were similar between the 2 groups. The proportion of urgent CEAs performed increased significantly after initiation of a vascular neurology service (4.1% [7 of 172] vs. 22.2% [49 of 221], P<0.0001). Per annum, urgent CEAs increased from 5.3% (4/75) in 2005 to 39.6% (25/63) in 2011. A vascular neurology service did not increase the number of nonurgent referrals. Urgent CEA indications were ocular ischemic events 4% (2/49), cerebral ischemic/infarction events 35% (17/49), crescendo TIAs 6% (3/49), acute stroke 45% (22/49), and stroke-in-evolution 10% (5/49). Mean NIHSS was 3.5 (range 0-24); mean TIA score was 5 (range 1-8). Although there were no statistical differences in 30-day outcomes, there was a trend toward a higher combined complication rate (stroke, death, myocardial infarction) in the urgent compared with the symptomatic but electively performed CEA group (7.1 % [3/49] vs. 2% [1/49]; P=.36). However, patients undergoing urgent CEA with an NIHSS<10 had no perioperative complications. CONCLUSIONS Collaboration with a vascular neurology team increased the volume of urgent CEAs over a 3-year period. In patients with mild-to-moderate strokes (NIHSS<10), urgent CEA perioperative outcomes approximate those for electively performed CEAs, suggesting improved care through a multidisciplinary approach.

Weekend Effect in Children With Stroke in the Nationwide Inpatient Sample

Background and Purpose— Studies have demonstrated differences in clinical outcomes in adult patients with stroke admitted on weekdays versus weekends. The study’s objective was to determine whether a weekend impacts clinical outcomes in children with ischemic stroke and hemorrhagic stroke. Methods— Children aged 1 to 18 years admitted to US hospitals from 2002 to 2011 with a primary discharge diagnosis of ischemic stroke or hemorrhagic stroke were identified by International Classification of Disease, 9th Revision, codes. Logistic regression estimated odds ratios and 95% confidence intervals for in-hospital mortality and discharge to a nursing facility among children admitted on weekends (Saturday and Sunday) versus weekdays (Monday to Friday), adjusting for potential confounders. Results— Of 8467 children with ischemic stroke, 28% were admitted on a weekend. Although children admitted on weekends did not have a higher in-hospital mortality rate than those admitted on weekdays (4.1% versus 3.3%; P=0.4), children admitted on weekends had a higher rate of discharge to a nursing facility (25.5% versus 18.6%; P=0.003). After adjusting for age, sex, and confounders, the odds of discharge to a nursing facility remained increased among children admitted on weekends (odds ratio, 1.5; 95% confidence interval, 1.1–1.9; P=0.006). Of 10 919 children with hemorrhagic stroke, 25.3% were admitted on a weekend. Children admitted on weekends had a higher rate of in-hospital mortality (12% versus 8%; P=0.006). After adjusting for age, sex, and confounders, the odds of in-hospital mortality remained higher among children admitted on weekends (odds ratio, 1.4; 95% confidence interval, 1.1–1.9; P=0.04). Conclusions— There seems to be a weekend effect for children with ischemic and hemorrhagic strokes. Quality improvement initiatives should examine this phenomenon prospectively.

Clinical Outcomes among Transferred Children with Ischemic and Hemorrhagic Strokes in the Nationwide Inpatient Sample

INTRODUCTION Children with ischemic stroke (IS) and hemorrhagic stroke (HS) may require interfacility transfer for higher level of care. We compared the characteristics and clinical outcomes of transferred and nontransferred children with IS and HS. METHODS Children aged 1-18 years admitted to hospitals in the United States from 2008 to 2011 with a primary discharge diagnosis of IS and HS were identified from the National Inpatient Sample database by ICD-9 codes. Using logistic regression, we estimated the odds ratios (OR) and 95% confidence intervals (CI) for in-hospital mortality and discharge to nursing facilities (versus discharge home) between transferred and nontransferred patients. RESULTS Of the 2815 children with IS, 26.7% were transferred. In-hospital mortality and discharge to nursing facilities were not different between transferred and nontransferred children in univariable analysis or in multivariable analysis that adjusted for age, sex, and confounding factors. Of the 6879 children with HS, 27.1% were transferred. Transferred compared to nontransferred children had higher rates of both in-hospital mortality (8% versus 4%, P = .003) and discharge to nursing facilities (25% versus 20%, P = .03). After adjusting for age, sex, and confounding factors, in-hospital mortality (OR 1.5, 95% CI 1.1-2.4, P = .04) remained higher in transferred children, whereas discharge to nursing facilities was not different between the groups. CONCLUSION HS but not IS was associated with worse outcomes for children transferred to another hospital compared to children who were not transferred. Additional study is needed to understand what factors may contribute to poorer outcomes among transferred children with HS.

Description of a novel telemedicine-enabled comprehensive system of care: drip and ship plus drip and keep within a system of stroke care delivery.

United States (US) and worldwide telestroke programs frequently focus only on emergency room hyper-acute stroke management. This article describes a comprehensive, telemedicine-enabled, stroke care delivery system that combines “drip and ship” and “drip and keep” models with a comprehensive stroke center primary hub at Ochsner Medical Center in New Orleans, advanced stroke-capable regional hubs, and geographically-aligned, “stroke-ready” spokes. The primary hub provides vascular neurology expertise via telemedicine and monitors care for patients remaining at regional hubs and spokes using a multidisciplinary team approach. By 2014, primary hub telestroke consults grew to ≈1000/year with 16 min average door to consult initiation and 20 min to completion, and 29% of ischemic stroke patients received recombinant tissue-type plasminogen activator (rtPA), increasing 275%. Most patients remained in hospitals close to home, but neurointensive care and interventional procedures were common reasons for primary hub transfer. Given the time sensitivity and expert consultation needed for complex acute stroke care delivery paradigms, telestroke programs are effective for fulfilling unmet care needs. Combining drip and ship and drip and keep management allows more patients to stay “local,” limiting primary hub transfer unless more advanced services are required. Post admission telestroke management at spokes increases personnel efficiency and can positively impact stroke outcomes.

Outcomes of transient ischemic attack in maintenance dialysis patients and those with chronic kidney disease

BACKGROUND In-hospital outcomes of transient ischemic attack (TIA) in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) requiring maintenance dialysis are largely unknown. We evaluated TIA-related in-hospital outcomes in these patients using a national database. METHODS Our study is observational in nature. Data from all adult (≥ 18 years) patients admitted to US hospitals between 2005 and 2011 with a primary discharge diagnosis of TIA and secondary diagnosis of CKD and ESRD were included using the Nationwide In-Patient Sample. We aimed to compare the following TIA-related outcomes between CKD and ESRD patients: (i) degree of disability (mainly functional status) derived from discharge destination, (ii) length of stay, (iii) charges of hospitalization, and (iv) mortality. The comparisons of TIA-related mortality and discharge outcomes between CKD and ESRD were analyzed after adjusting for potential confounders using logistic regression analysis. We adjusted for age, sex, co-morbidities, hospital size and hospital teaching status. RESULTS A total of 18 316 dialysis and 67 256 CKD patients were admitted with TIA in the study period (2005-11). On univariate analysis, there was no difference in the rates of moderate-to-severe disability (20.5% versus 20.2%, P = 0.7) and in-hospital mortality (0.4% versus 0.2%, P = 0.07) in ESRD patients compared with those with CKD. After adjusting for age, sex and potential confounders, ESRD patients with TIA had higher odds of moderate-to-severe disability at discharge [odds ratio (OR): 1.53, 95% confidence interval (CI): 1.37-1.71, P ≤ 0.0001] and in-hospital death (OR: 2.87, 95% CI: 1.29-6.37, P = 0.009). CONCLUSION ESRD patients with TIA have significantly higher rates of moderate-to-severe disability at discharge and in-hospital mortality when compared with the patients of other stages of CKD who are not dialysis-dependent.

Operator for stroke interventions

The requisites of training for neuroendovascular procedures have been debated. A report by Jennifer Byrne was published in the July/August 2015 issue of Cardiology Today Intervention . In the report, ‘Acute stroke: a new target for endovascular therapy; experience and availability make interventional cardiologists uniquely qualified for acute stroke’, the author summarizes the findings of recent randomized controlled trials for endovascular treatment of acute ischemic stroke and then emphasizes the shortage of providers of neurointerventional stroke treatment. However, this is a controversial topic and many have suggested that too many neurointerventionalists are being trained in the USA.1 ,2 The report suggests that cardiologists should fill this perceived lack of neurointerventionalists by treating patients in small rural hospitals rather than sending them to a stroke center. We believe that this would be a giant leap backwards in quality and safety. Treatment of strokes in small rural hospitals by individuals with limited training and experience and with support staff who are untrained in neurologic care seems unsafe. This idea undermines the hard work being done by hospitals that obtain both Primary and Comprehensive Stroke Center certifications, …

E-095 what are the risk factors and outcomes relating to hemorrhagic transformation with large vessel occlusion in the anterior circulation at a comprehensive stroke center?

Purpose Ochsner Clinic Foundation in New Orleans, LA is a certified comprehensive stroke center which includes a hub and spoke type of telestroke system with over 30 referral hospitals. The purpose of this study is to determine the incidence, possible correlative factors, and clinical significance of different types of hemorrhages in patients who are being considered for and treated with mechanical thrombectomy (MT). Materials and methods 195 consecutive patients were retrospectively analyzed from 1/1/12–7/1/14. Inclusion criteria were presentation with acute stroke signs, CT perfusion/CT angiography showing proximal MCA/intracranial ICA occlusion. Four patients had no follow-up imaging. An interventional neuroradiologist (JM) evaluated imaging for the initial presence of basal ganglia involvement on presenting CT or CTP. Hemorrhages were subgrouped by type (HI1, HI2, PH1, PH2). Combined groups of HI and PH were used when greater sample size was required. Risk factors and presenting signs/symptoms were obtained by retrospective chart review. Discharge and follow-up modified Rankin Scale (mRS) and the National Institute of Health Stroke Scale (NIHSS) were also found on chart review. Evaluation was performed using linear and logistic regressions. Results The overall rate of hemorrhage was 53/191, including HI1 (n = 16), HI2 (n = 15), PH1 (n = 7), PH2 (n = 13), and no hemorrhage (n = 138). Thrombectomy was associated with an increased rate of HI (OR 2.3, p = 0.03). Although the rate of PH in MT patients (11/72) was greater than the rate of PH in nonthrombectomy patients (9/123), this was not significant (p = 0.09). The rates of PH2 were 8/72 (thrombectomy) and 5/123 (nonthrombectomy). The following correlated with HI in MT patients: transfer from another institution (OR = 1.3, p = 0.028), dysarthria as presenting symptom (OR = 1.4, p = 0.01), obesity (OR = 2.2, p = 0.0003), ETOH abuse (OR = 1.4, p = 0.012), and BG involvement (OR = 1.35, p = 0.003). In all patients combined, basal ganglia involvement was associated with HI (OR = 6.5, p = 0.009), PH (OR = 10.1, p = 0.034), and death (OR = 5.3, p = 0.037). The presence of HI in MT patients has a statistically significant correlation with higher 90 day NIHSS (p = 0.03). PH correlates with poor outcomes in MT patients on both 90 day NIHSS (p = 0.01) and 90 day mRS (p = 0.008). BG involvement did not have a statistically significant correlation with 90 day NIHSS (p = 0.5), 90 day mRS (p = 0.46), or death (OR = 1.3, p = 0.77) in MT patients. BG involvement did have statistically significant correlations with 90 NIHSS (p = 0.04) and 90 day mRS (p = 0.006) in patients treated with TPA alone. Conclusion MT is associated with an increased rate of HI hemorrhages but not PH hemorrhages. HI hemorrhages have no correlation with death or mRS. mRS may be too insensitive to detect deficits relating to HI hemorrhages, NIHSS should be used in studies investigating clinical outcomes relating to HI hemorrhages. BG involvement may correlate with both HI and PH hemorrhages in patients treated with and without MT. However, having BG involvement does not seem to correlate with a worse prognosis in MT patients with any type of hemorrhage. Disclosures G. Bennett: None. M. Al Hasan: None. G. Vidal: 3; C; Penumbra. Q. Luo: None. J. Milburn: None.