Saqib A Chaudhry

Impact of onset-to-reperfusion time on stroke mortality: a collaborative pooled analysis.

Background— Onset-to-reperfusion time has been reported to be associated with clinical prognosis. However, its impact on mortality remained to be assessed. Using a collaborative pooled analysis, we examined whether early mortality after successful endovascular treatment is time dependent. Methods and Results— In a collaborative pooled analysis of 7 endovascular databases, we assessed the impact of onset-to-reperfusion time in large-artery occlusion (internal carotid artery or middle cerebral artery) on outcomes. Successful reperfusion was defined as complete or partial restoration of blood flow within 8 hours from symptom onset. Primary outcome was 90-day all-cause mortality. Secondary outcomes included 90-day favorable outcome (modified Rankin Scale score, 0–2), 90-day excellent outcome (modified Rankin Scale score, 0–1), and occurrence of any intracerebral hemorrhage within 24 to 36 hours after treatment. A total of 480 cases with successful reperfusion (median time, 285 minutes) contributed to the present pooled analysis (120 with internal carotid artery occlusion and 360 with isolated middle cerebral artery occlusion). Increasing onset-to-reperfusion time was associated with an increased rate of mortality and intracerebral hemorrhage and with a decreased rate of favorable and excellent outcomes, without heterogeneity across studies. The adjusted odds ratio for each 30-minute time increase was 1.21 (95% confidence interval, 1.09–1.34; P<0.001) for mortality, 0.79 (95% confidence interval, 0.72–0.87) for favorable outcome, 0.78 (95% confidence interval, 0.71–0.86) for excellent outcome, and 1.21 (95% confidence interval, 1.10–1.33) for intracerebral hemorrhage. Conclusion— Onset-to-reperfusion time affects mortality and favorable outcome and should be considered the main goal in acute stroke patient management.

National Trends in Utilization and Outcomes of Endovascular Treatment of Acute Ischemic Stroke Patients in the Mechanical Thrombectomy Era

Background and Purpose— Because several new devices for mechanical thrombectomy have become available, the outcomes of patients undergoing endovascular treatment for acute ischemic stroke are expected to improve in the United States. We performed this analysis to evaluate trends in utilization of endovascular treatment and associated rates of death and disability among acute ischemic stroke patients over a 6-year period, including further assessment within age strata. Methods— We obtained data for patients admitted to hospitals in the United States from 2004 to 2009 with a primary diagnosis of ischemic stroke using a large national database. We determined the rate and pattern of utilization, and associated in-hospital outcomes of endovascular treatment among ischemic stroke patients and further analyzed trends within age strata. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition and compared between 2 time periods: 2004 to 2007 (post-MERCI) and 2008 to 2009 (post-Penumbra) approvals Results— Of the 3 292 842 patients admitted with ischemic stroke, 72 342 (2.2%) received intravenous thrombolytic treatment and 13 799 (0.4%) underwent endovascular treatment. There was a 6-fold increase in patients who underwent endovascular treatment (0.1% of ischemic strokes in 2004 vs 0.6% in 2009; P<0.001), with the patients aged ≥85 years having the lowest rate of utilization (0.2%). The rates of intracranial hemorrhage remained unchanged throughout the 6 years. In multivariate logistic regression analysis, after adjusting for age, gender, presence of hypertension, congestive heart failure, renal failure, and secondary intracranial hemorrhages, there was no difference in the rate of minimal disability between the 2 study intervals (2004–2007 vs 2008–2009; odds ratio, 0.8; 95% confidence interval, 0.7–1.04; P=0.11). Mortality decreased while moderate to severe disability increased for patients treated during 2008 to 2009 (odds ratio, 0.7; 95% confidence interval, 0.6–0.9; P=0.007; and odds ratio, 1.4; 95% confidence interval, 1.2–1.7; P=0.0002). Conclusion— There has been a significant increase in the proportion of acute ischemic stroke patients receiving endovascular treatment over the 6 years and reduction in in-hospital mortality. Our results highlight the need to implement endovascular techniques in a balanced manner across various age groups that also results in the reduction of disability in addition to mortality.

Discharge Destination as a Surrogate for Modified Rankin Scale Defined Outcomes at 3- and 12-Months Poststroke Among Stroke Survivors

OBJECTIVE To determine the predictive value of discharge destination as a surrogate for defining unfavorable outcome at 3- and 12-months poststroke. DESIGN Analysis of the prospectively collected data from a randomized, placebo-controlled trial in patients with ischemic stroke presenting within 3 hours of symptom onset. SETTING Post hoc analysis of patients recruited in a clinical trial. PARTICIPANTS Patients (N=530) discharged alive from the hospital after ischemic stroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Positive and negative predictive value and likelihood ratios of discharge destination for unfavorable outcome at 3- and 12-months poststroke defined by a Modified Rankin Scale (MRS) score of 2 to 6, 3 to 6, or 4 to 6. A likelihood ratio indicates how many times more (or less) likely a particular discharge destination is seen in patients with an unfavorable outcome compared with those without unfavorable outcome. RESULTS The positive predictive value of nursing home and rehabilitation facility discharges was highest for unfavorable outcome defined by an MRS score of 2 to 6 (95%) and rehabilitation facility (89%) at 3-months poststroke, respectively. The positive predictive value of rehabilitation facility/nursing home (90%) was also highest for unfavorable outcomes defined by an MRS score of 2 to 6 compared with those defined by MRS scores of 3 to 6 (79%) and 4 to 6 (57%). The positive likelihood ratio was highest for nursing home discharges (13; 95% confidence interval [CI], 4.1-41) followed by rehabilitation facility discharges for unfavorable outcome defined by an MRS score of 2 to 6 at 3-months poststroke (5.3; 95% CI, 3.5-7.9). The negative likelihood ratio was the highest for home discharge for unfavorable outcome defined by an MRS score of 2 to 6 (4.5; 95% CI, 3.4-6.1). A similar pattern was observed with unfavorable outcome defined using various thresholds at 12 months. CONCLUSIONS Discharge destination can provide high predictive values and likelihood ratios for death and disability at 3-months poststroke, as defined by an MRS of score of 2 to 6.

Thrombolytic Treatment of Patients With Acute Ischemic Stroke Related to Underlying Arterial Dissection in the United States

OBJECTIVE To determine the outcomes related to thrombolytic treatment of an acute ischemic stroke secondary to an arterial dissection in a large national cohort. DESIGN Retrospective database study. SETTING Nationwide Inpatient Sample data files from 2005 to 2008. PATIENTS We determined the frequency of underlying arterial dissection among patients with acute ischemic stroke treated with thrombolytic treatment and associated in-hospital outcomes. MAIN OUTCOME MEASURES All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. RESULTS Of the 47,899 patients with ischemic stroke who received thrombolytic treatment, 488 (1%) had an underlying dissection. The intracranial hemorrhage rates did not differ between patients with ischemic stroke with or without underlying dissection who received thrombolytic treatment (6.9% vs 6.4%). After adjusting for age, sex, hypertension, diabetes mellitus, renal failure, congestive heart failure, and hospital teaching status, presence of dissection was associated with higher rates of moderate disability (odds ratio, 2.8; 95% confidence interval, 1.7-4.6; P < .001) at discharge. The interaction terms between dissection and thrombolytic treatment among all patients with ischemic stroke for predicting in-hospital mortality (P = .84) and minimal disability (P = .13) were not statistically significant. CONCLUSIONS The adjusted rate of favorable outcomes is lower among patients with ischemic stroke with underlying arterial dissection following thrombolytic treatment compared with those without underlying dissections. However, the observed lower rates are not influenced by thrombolytic treatment.

Microcatheter to Recanalization (Procedure Time) Predicts Outcomes in Endovascular Treatment in Patients with Acute Ischemic Stroke: When Do We Stop?

This study addresses the relationship among procedure time, recanalization, and clinical outcomes in patients with acute ischemic stroke undergoing endovascular treatment. Demographics, NIHSS scores before and 1 day after the procedure, and modified Rankin Scale scores were assessed in 209 patients. Patients with procedure times ≤30 minutes had lower rates of unfavorable outcome at discharge compared with patients with procedure times ≥30 minutes. Rates of favorable outcomes in endovascularly treated patients after 60 minutes were lower than rates observed with placebo treatment. Unfavorable outcome was positively associated with age, admission NIHSS strata, and longer procedure times. BACKGROUND AND PURPOSE: Endovascular treatment for acute ischemic stroke consists of various mechanical and pharmacologic modalities used for recanalization of arterial occlusions. We performed this study to determine the relationship among procedure time, recanalization, and clinical outcomes in patients with acute ischemic stroke undergoing endovascular treatment. MATERIALS AND METHODS: We analyzed data from consecutive patients with acute ischemic stroke who underwent endovascular treatment during a 6-year period. Demographic characteristics, NIHSS score before and 24 hours after the procedure, and discharge mRS score were ascertained. Procedure time was defined by the time interval between microcatheter placement and recanalization or completion of the procedure. We estimated the procedure time after which favorable clinical outcome was unlikely, even after adjustment for age, time from symptom onset, and admission NIHSS scores. RESULTS: We analyzed 209 patients undergoing endovascular treatment (mean age, 65 ± 16 years; 109 [52%] men; mean admission/preprocedural NIHSS score, 15.3 ± 6.8). Complete or partial recanalization was observed in 176 (84.2%) patients, while unfavorable outcome (mRS 3–6) was observed in 138 (66%) patients at discharge. In univariate analysis, patients with procedure time ≤30 minutes had lower rates of unfavorable outcome at discharge compared with patients with procedure time ≥30 minutes (52.3% versus 72.2%, P = .0049). In our analysis, the rates of favorable outcomes in endovascularly treated patients after 60 minutes were lower than rates observed with placebo treatment in the Prourokinase for Acute Ischemic Stroke Trial. In logistic regression analysis, unfavorable outcome was positively associated with age (P = .0012), admission NIHSS strata (P = .0017), and longer procedure times (P = .0379). CONCLUSIONS: Procedure time in patients with acute ischemic stroke appears to be a critical determinant of outcomes following endovascular treatment. This highlights the need for procedure time guidelines for patients being considered for endovascular treatment in acute ischemic stroke.

Drip-and-Ship Thrombolytic Treatment Paradigm Among Acute Ischemic Stroke Patients in the United States

Background and Purpose— To provide a national assessment of thrombolytic administration using drip-and-ship treatment paradigm. Methods— Patients treated with the drip-and-ship paradigm among all acute ischemic stroke patients treated with thrombolytic treatment were identified within the Nationwide Inpatient Sample. Thrombolytic utilization, patterns of referral, comparative in-hospital outcomes, and hospitalization charges related to drip-and-ship paradigm were determined. All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. Results— Of the 22 243 ischemic stroke patients who received thrombolytic treatment, 4474 patients (17%) were treated using drip-and-ship paradigm. Of these 4474 patients, 81% were referred to urban teaching hospitals for additional care, and 7% of them received follow-up endovascular treatment. States with a higher proportion of patients treated using the drip-and-ship paradigm had higher rates of overall thrombolytic utilization (5.4% versus 3.3%; P<0.001). The rate of home discharge/self-care was significantly higher in patients treated with drip-and-ship paradigm compared with those who received thrombolytics through primary emergency department arrival in the multivariate analysis (OR, 1.198; 95% CI, 1.019–1.409; P=0.0286). Conclusions— One of every 6 thrombolytic-treated patients in United States is treated using drip-and-ship paradigm. States with the highest proportion of drip-and-ship cases were also the states with the highest thrombolytic utilization.

Diagnosis of Stroke by Emergency Medical Dispatchers and Its Impact on the Prehospital Care of Patients

BACKGROUND Emergency medical dispatchers represent the first line of communication with a patient, and their decision plays an important role in the prehospital care of stroke. We evaluated the rate and accuracy of stroke diagnosis by dispatchers and its influence in the prehospital care of potential stroke patients. METHODS We analyzed the 2009 National Emergency Medical Services Information System. Study population was based on the diagnosis of stroke made by emergency medical technicians (EMT). This was then divided in those coded as stroke/cerebrovascular accident versus others reported by dispatchers and compared with each other. RESULTS In all, 67,844 cases were identified as stroke by EMT, but transportation time was available for 52,282 cases that represented the final cohort. Cases identified as stroke by dispatchers were 27,566 (52.7%). When this group compared with stroke cases not identified by dispatchers, we found that the mean age was significantly higher (71.2 versus 68.6 years, P<.0001); advanced life support was dispatched more frequently (84% versus 72.8%, P<.0001), dispatchers offered help and instructions to the caller more frequently, and they arrived at a facility at a shorter time (41.8 versus 49.8 minutes, P<0001). Sensitivity and specificity for the diagnosis of stroke by dispatchers were 34.61 and 99.46, respectively. CONCLUSIONS Recognition of symptoms and diagnosis of a potential stroke by dispatchers positively affect the care of patients by decreasing the arrival time to a hospital and providing the highest level of prehospital care possible. Education is needed to increase dispatchers detection of stroke cases.

Prevalence and characteristics of concurrent down syndrome in patients with moyamoya disease.

BACKGROUND An association between moyamoya disease and Down syndrome appears to exist on the basis of reported anecdotal cases in the literature. OBJECTIVE To determine the prevalence of Down syndrome associated with moyamoya disease in inpatients and to identify the demographic and clinical features of moyamoya disease that may be unique when associated with Down syndrome. METHODS In this observational study, we analyzed data from the Nationwide Inpatient Sample between 2002 and 2009 using International Classification of Diseases codes for moyamoya disease and Down syndrome for patient identification. Data including patient age, sex, race/ethnicity, secondary diagnosis, procedures, hospital costs, and patient outcomes were obtained. RESULTS From 2002 to 2009, an estimated 518 patients (mean ± SD age, 16.2 ± 1.68 years) with coexisting moyamoya disease and Down syndrome were admitted. The estimated prevalence was 3.8% (3760 per 100,000) among patients admitted with moyamoya disease and 9.5% (9540 per 100,000) among moyamoya patients < 15 years of age. Patients admitted with moyamoya disease and Down syndrome were most frequently white and Hispanic (P = .02). They were more likely to present with ischemic stroke and less commonly with hemorrhagic stroke (15.3% and 2.7%, respectively; P < .05). CONCLUSION This is the first study to estimate the prevalence of Down syndrome in patients with moyamoya disease. The 26-fold-greater prevalence of Down syndrome in patients with coexisting moyamoya disease compared with the prevalence of Down syndrome among live births (145 per 100,000) highlights the need for a better understanding of the common pathophysiology of the 2 conditions.

Neurointerventional Procedural Volume per Hospital in United States Implications for Comprehensive Stroke Center Designation

Background and Purpose— Availability of neurointerventional procedures is recommended as a necessary component of a comprehensive stroke center by various regulatory guidelines that also emphasize adequate procedural volumes. We studied the volumes of neurointerventional procedures performed in various hospitals across the United States with subsequent comparisons with rates of minimum procedural volumes recommended by various professional bodies or used in clinical trials to ensure adequate operator experience. Methods— We reviewed the Nationwide Inpatient Sample database in the United States for the years 2005 to 2008. Using International Classification of Disease—Clinical Modification, 9th revision, and Medicare severity diagnosis-related group codes, we identified among hospitals that admit stroke patients those that met the minimum criteria for overall and individual procedural volumes specified in various guidelines. We then compared the characteristics between the high-volume hospitals that performed at least 100 cervicocerebral angiograms and met ≥1 other procedural criterion (n=79) and low-volume hospitals (n=958). Results— Proportions of hospitals that met individual procedural volume criteria over the 4-year period according to procedure were: cervicocerebral angiography (7.0%–7.8%); endovascular acute ischemic stroke treatments (0.4%–2.6%); carotid angioplasty/stent placement (3.0%–5.3%); intracranial angioplasty/stent placement (0.3%–1.3%); and aneurysm embolization (1.3%–2.6%). There were significant trends for increasing numbers of all the endovascular procedures except intracranial angioplasty/stent placement over the course of 4 years. The high-volume hospitals were more likely to be urban teaching hospitals (70.9% versus 13.1%; P<0.001), had larger bed size (79.7% versus 26.9%; P<0.001), and had significantly higher rates of hemorrhagic stroke admissions and lower rates of transient ischemic attack admissions. Urban teaching location/status (OR, 8.92; CI, 4.3–18.2; P<0.001) and large bed size (OR, 4.40; CI, 2.0–9.5; P<0.001) remained as independent predictors of a high-volume hospital when adjusted for age, gender, risk factors, and stroke subtype. Conclusions— There are very few hospitals in the United States that meet all the neurointerventional procedural volume criteria for all endovascular procedures recommended to ensure adequate operator experience. Our results support the creation of specialized regional centers for ensuring adequate procedural volume within treating hospitals.

Outcome of the 'Drip-and-Ship' Paradigm among Patients with Acute Ischemic Stroke: Results of a Statewide Study.

Background: The ‘drip-and-ship’ paradigm denotes a treatment regimen in patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated at the emergency department (ED) of a community hospital, followed by transfer within 24 h to a comprehensive stroke center. Although the drip-and-ship paradigm has the potential to increase the number of patients who receive IV rt-PA, comparative outcomes have not been assessed at a population-based level. Methods: Statewide estimates of thrombolysis, associated in-hospital outcomes, and hospitalization charges were obtained from 2008–2009 Minnesota Hospital Association data for all patients hospitalized with a primary diagnosis of ischemic stroke. Patients who were assigned the drip-and-ship code [International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) V45.88] were classified under the drip-and-ship paradigm. Patients who underwent thrombolysis (ICD-9-CM code 99.10) without drip-and-ship code were classified as primary ED arrival. Patient outcomes were analyzed after stratification into patients treated with IV rt-PA through primary ED arrival or drip-and-ship paradigm. Results: Of the 21,024 admissions, 602 (2.86%) received IV rt-PA either through primary ED arrival (n = 473) or the drip-and-ship paradigm (n = 129). IV rt-PA was administered in 30 hospitals, of which 13 hospitals used the drip-and-ship paradigm; the number of patients treated with the drip-and-ship paradigm varied from 1 to 40 between the 13 hospitals. The rates of secondary intracerebral or subarachnoid hemorrhage were higher in patients treated with IV rt-PA through primary ED arrival compared with those treated with the drip-and-ship paradigm (8.5 vs. 3.1%, respectively; p = 0.038). The in-hospital mortality rate was similar among ischemic stroke patients receiving IV rt-PA through primary ED arrival or the drip-and-ship paradigm (5.9 vs. 7.0%, respectively). The mean hospital charges were USD 65,669 for primary ED arrival and USD 47,850 for drip-and-ship-treated patients (p < 0.001). The rate of admission to a certified stroke center as final destination for acute hospitalization was higher in patients treated by drip-and-ship paradigm compared with those treated by primary ED arrival mode (p = 0.015). Conclusions: The results of the drip-and-ship paradigm compare favorably with IV rt-PA treatment through primary ED arrival in this statewide study. Our results support the recommendations of various professional organizations that the drip-and-ship method of IV rt-PA administration for stroke may be an effective option for increasing the utilization of IV rt-PA on a large scale.