L. T. Smurawska

Cost of acute stroke care in Toronto, Canada.

Background and Purpose Stroke cost consumes a large proportion of the gross domestic product in all developed countries, and while health care costs are rising, the ability to contain them is diminishing. Methods We calculated the cost of acute stroke care for all first admissions to a teaching hospital in Toronto, Canada, in 1991 through 1992 for 285 consecutive patients. Results The average cost per patient was

Mass effect and death from severe acute stroke

27 500 Canadian, and strokes in men cost less than in women (

Simple Visual Analysis of Brain Perfusion on HMPAO SPECT Predicts Early Outcome in Acute Stroke

23 000 versus

Changing Practice and Costs of Carotid Endarterectomy in Toronto, Canada

32 000 Canadian), for a total cost of

Cost considerations in the pharmacological prevention and treatment of stroke.

8 million Canadian over 2 years. More women died than men (34% versus 17%, P<.02), mainly from systemic complications of stroke, but because women stayed hospitalized longer, they cost more in the long term. The major factor determining cost was social support, and more men than women went home or to rehabilitation units (P<.02). Family support was greater for men (82%) than women (39%, P<.0002). Conclusions Significant cost reductions are more likely to be achieved by altering discharge policies and improving social conditions for early return to the home than by reducing laboratory or medical personnel costs.

Decreasing Costs of Stroke Hospitalization in Toronto

Background: In severe acute stroke, the degree of midline cerebral displacement is related to level of consciousness but not to survival. Early identification of patients at high risk of death from mass effect would assist patient management decisions. Methods: We measured lesion volume, horizontal pineal displacement (PD), and horizontal septum pellucidum displacement (SD) on axial CT of consecutive patients with severe (Canadian Neurological Scale score ≤5) acute hemispheric stroke. We correlated CT measurements with the probability of 14-day survival. Results: Forty-six (39%) of 118 patients died within 14 days and 72 (61%) died within 1 year following stroke. Crude risk factors for 14-day mortality were as follows: lesion volume ≥400 ml, SD ≥9 mm, PD ≥4 mm, intraventricular hemorrhage, and coma on admission. Only SD (p = 0.001) and coma on admission (p = 0.019) remained significant in multivariate analysis, but PD was highly correlated with SD (r = 0.82). PD of≥4 mm on a scan performed within 48 hours of stroke onset identified patients with a low probability of 14-day survival (0.16; CI 0 to 0.32) with a specificity of 89% and a sensitivity of 46%. Conclusions: The degree of horizontal midline cerebral displacement correlates with the likelihood of death following stroke. Patients with ≥4 mm PD on CT performed within 48 hours of stroke onset are at high risk for early death.

Should patients with stroke see a neurologist

BACKGROUND AND PURPOSE Single-photon emission computed tomography (SPECT) is used in patients with acute stroke but as yet is of controversial value. We investigated an association of brain perfusion changes in stroke patients with stroke severity, volume of brain damage, and recovery. METHODS Consecutive patients with hemispheric stroke were studied prospectively with serial neurological examinations using the Canadian Neurological Scale (CNS), CT. and 99mTc-hexamethylpropyleneamine oxime (HMPAO) SPECT. Visual SPECT patterns of brain perfusion (normal, high, mixed, low, and absent) were correlated with the severity of stroke, lesion volume, and short-term outcome. RESULTS SPECT studies were performed in a total of 458 consecutive acute stroke patients within 2 weeks after the onset (mean time, 5 days; range, 1 to 12 days). SPECT perfusion patterns correlated with stroke severity (CNS score) during the first 2 weeks (P < .001). Focal absence of brain perfusion on SPECT was associated with the largest volume of brain damage: 104 +/- 84 mL (P < .0001). SPECT perfusion patterns predicted the shortterm outcome: 97% of patients with normal and increased HMPAO uptake made good recovery, 52% of those with decreased perfusion had moderate stroke, and 62% of patients with absent patterns fared badly. In a multiple logistic regression model, admission CNS scores had the strongest predictive value (P = .0001). SPECT had its own prognostic value independent of clinical judgment (P = .03). SPECT statistically improved predictive power of the CNS score (+1% receiver operating characteristic curve area, [X2]2 = 20, P < .001) because of distinction between focal decrease or absence of brain perfusion in patients studied within the first 72 hours of stroke. CONCLUSIONS Visual brain perfusion patterns correlate with the extent, severity, and short-term outcome of hemispheric stroke. HMPAO SPECT may improve the prognostic value of clinical examination if performed during the first 72 hours of stroke.

Regarding “A comparison of carotid angioplasty with stenting versus endarterectomy with regional anesthesia”

BACKGROUND AND PURPOSE During our annual audits of carotid endarterectomy (CEA) in Toronto metropolitan hospitals, we have been aware of major changes in the practice of this operation in recent years. To evaluate the effect of changing practice on costs of carotid endarterectomy, we have therefore compared the effects of changes in length of stay, complication rates, and other variables on cost during the last 3 years for which we have complete data. METHODS We evaluated 757 consecutive patients, of whom 600 had CEA procedures in 3 teaching hospitals, and 190 procedures in 2 community hospitals in metropolitan Toronto. We estimated costs using a specially designed computer program, Transitional System Incorporated, including surgical complications, in patients admitted between January 1994 and December 1996. RESULTS There was a significant decrease in length of stay in both groups of hospitals, mainly due to preoperative outpatient evaluation but also due to lower complication rates, which probably reflect an increase in asymptomatic surgery in both hospital groups. Costs fell from approximately

Is asymptomatic carotid surgery cost-effective?

8000 per procedure to

Stroke patients and the neurologist

5000 in asymptomatic patients and from approximately