Nora Lee

Acute Stroke Management in the Elderly

Background and Purpose: Though the proportion of elderly stroke patients is increasing, patients >80 years are often excluded from clinical stroke trials. We reviewed the management of older patients presenting with acute ischemic stroke (AIS) and assessed the safety and efficacy of recombinant tissue plasminogen activator (rtPA) administration in a community-based setting. Methods: A retrospective review of patients >80 years (n = 341) admitted to a community stroke center with AIS were compared to their younger counterparts (n = 690) using the stroke center database from April 2003 to December 2005. Parameters that were measured included admission and discharge NIH Stroke Scale (NIHSS), rate of thrombolytic treatment, the frequency and etiology of thrombolytic exclusion criteria and complications from rtPA for the different aged populations. Additional data were collected for Barthel Index at 12 months. Results: A total of 166 patients underwent thrombolysis. Older patients were not delayed in reaching the hospital within 3 h of stroke onset (182/690, 26%, in the <80 cohort vs. 98/341, 29%, in the ≧80 cohort). Although the overall rates of tPA use were similar in both the young and aged cohort, older patients were less likely to be treated with rtPA because of reasons not listed as exclusion criteria (17% in the <80 cohort vs. 32% in the ≧80 cohort).The older group did not have an excess risk of intracranial hemorrhage following rtPA infusion despite equivalent NIHSS on admission (13.5 in the <80 cohort vs. 12.4 in the ≧80 cohort). Both groups showed improvement in NIHSS following thrombolytic treatment with a drop of 7.7 points in the younger age group and 5.6 points in the older group. Elderly patients treated with rtPA had a comparable 12-month modified Barthel Index score to younger cohorts. Conclusions: Early treatment with rtPA in patients >80 years appears to be both safe and efficacious. Treated patients showed improvements both acutely (a decrease in NIHSS at 72 h) and chronically, as shown by a sustained improvement in the Barthel Index. A large number of elderly patients were excluded from rtPA treatment despite arriving within the time frame of treatment for reasons not considered as traditional exclusion criteria. Older patients with AIS can be treated safely with thrombolytic therapy in a community setting. This therapy should not be withheld on the basis of age.

Association of physical functioning with same-hospital readmission after stroke.

Bohannon RW, Lee N: Association of physical functioning with same-hospital readmission after stroke. Am J Phys Med Rehabil 2004;83:434–438. Objective:Readmission after hospitalization for stroke is an important outcome. We sought to document the frequency of same-hospital readmission and to determine the relative value of physical functioning as a predictor of the outcome. Design:Consenting patients (n = 228) who were admitted for ischemic stroke were characterized according to demographics, stroke severity, and self-reported prestroke and postadmission physical functioning. The hospitals administrative database was used to track readmissions during the year after index hospitalization. Results:Same-hospital readmissions were experienced by 37.3% of the patients. The readmissions usually occurred within 100 days of discharge. The most common readmission diagnosis was stroke (14.1%). Lower prestroke and postadmission physical functioning (as reflected by dichotomous Barthel index scores) were weak but significant predictors of readmission (r = −0.165 and −0.268, respectively). Regression analysis showed that once postadmission physical functioning was accounted for, neither prestroke functioning nor any other measured variable added to the explanation of same-hospital readmission. Conclusion:The importance of physical functioning goes beyond rehabilitation. It is a potentially modifiable variable with implications for readmission.

Interventional Stroke Therapies in the Elderly: Are We Helping?

Our fellows are called in many times to assess older patients with stroke. This article attempts to answer if we are really helping these patients by performing thrombolysis. The authors compared patients with acute stroke (n=37) who were older than 75 years of age with a control group (n=70) who were younger than 75 years. NIHSS scores were similar in both groups. Patients older than 75 years were less likely to receive endovascular treatments. Older patients had higher rates of symptomatic intracranial hemorrhage, disability, and mortality. BACKGROUND AND PURPOSE: It is unclear whether endovascular therapies for the treatment of AIS are being offered or are safe in older adults. The use and safety of endovascular interventions in patients older than 75 years of age were assessed. MATERIALS AND METHODS: A retrospective review of patients with AIS 75 years or older (n = 37/1064) was compared with a younger cohort (n = 70/1190) by using an established data base. Admission and discharge NIHSS scores, rates of endovascular treatment, SICH, in-hospital mortality, and the mBI were assessed. RESULTS: Rates of endovascular treatments were significantly lower in older patients (5.9% in the younger-than-75-year versus 3.5% in the older-than-75-year cohort, P = .007). Stroke severity as measured by the NIHSS score was equivalent in the 2 age groups. The mBI at 12 months was worse in the older patients (mild or no disability in 52% of the younger-than-75-year and 22% in the 75-year-or-older cohort, P = .006). Older patients had higher rates of SICH (9% in younger-than-75-year versus 24% in the 75-year-or-older group, P = .04) and in-hospital mortality (26% in younger-than-75-year versus 46% in the 75-year-or-older group, P = .05). CONCLUSIONS: Patients older than 75 years of age were less likely to receive endovascular treatments. Older patients had higher rates of SICH, disability, and mortality. Prospective randomized trials are needed to determine the criteria for selecting patients most likely to benefit from acute endovascular therapies.

Functional gains during acute hospitalization for stroke.

Objectives. 1) Confirm clinimetric suitability of 5 Functional Independence Measure TM (FIM) items for characterizing functional independence. 2) Describe functional changes and relationships between selected variables and functional independence at discharge and functional change. Methods. For 451 patients hospitalized for acute stroke, scores were recorded at admission and discharge for 5 FIM items (transfers, eating, walking, expression, and memory). The sum of the 5 FIM items and functional change between admission and discharge were calculated. Results. The FIM scores were internally consistent (alpha = .894 and .918) and reflected 1 factor. Functional independence increased (t = 17.46, P < .001) over a mean 5.5 days. Regression analysis showed the same variables (admission function, NIHSS score, length of stay, age, and total therapy units) to best predict discharge function (R 2 = .804) and function change (R 2 = .184). Conclusions. Together, 5 easily observed FIM items demonstrated that functional independence increased during hospitalization. Discharge function and functional change were predicted significantly (but weakly) by therapy units.

Thrombolysis in Right versus Left Hemispheric Stroke

BACKGROUND Recent evidence has suggested that patients with right hemispheric stroke (RHS) present later to an emergency department, have a lower chance to receive intravenous (IV) recombinant tissue plasminogen activator (t-PA), and have poorer clinical outcomes than do patients with left hemispheric stroke (LHS). METHODS We analyzed the rate of IV t-PA administration with respect to the side of the affected hemisphere in a large community population, to determine whether a difference exists. The study population was a large prospective cohort of patients with acute stroke treated with IV t-PA at our hospitals stroke center (October 2000 to October 2006). RESULTS Of 2,932 patients presenting with ischemic stroke, 953 met criteria for study inclusion. In all, 151 patients received IV t-PA. Between groups, there was no significant difference in presentation within 3 hours after acute stroke (P=.180). There was no difference in the use of IV t-PA between patients with RHS and LHS (P=.237). CONCLUSIONS There was no difference with respect to affected hemisphere in time to presentation to the emergency department. Furthermore, there was no difference in the rate of IV t-PA administration for patients with RHS versus LHS. This finding is in contrast to previous research on IV t-PA use in hemispheric stroke and may reflect improved recognition of right hemispheric syndromes.