Acute Ischemic Stroke Events Research Articles

Administrative data underestimate acute ischemic stroke events and thrombolysis treatments: Data from a multicenter validation survey in Italy.

BackgroundInforming health systems and monitoring hospital performances using administrative data sets, mainly hospital discharge data coded according to International-Classification-Diseases-9edition-Clinical-Modifiers (ICD9-CM), is now commonplace in several countries, but the reliability of diagnostic coding of acute ischemic stroke in the routine practice is uncertain. This study aimed at estimating accuracy of ICD9-CM codes for the identification of acute ischemic stroke and the use of thrombolysis treatment comparing hospital discharge data with medical record review in all the six hospitals of the Florence Area, Italy, through 2015.MethodsWe reviewed the medical records of all the 3915 potential acute stroke events during 2015 across the six hospitals of the Florence Area, Italy. We then estimated sensitivity and Positive Predictive Value of ICD9-CM code-groups 433*1, 434*1 and thrombolysis code 99.10 against medical record review with clinical adjudication. For each false-positive case we obtained the actual diagnosis. For each false-negative case we obtained the primary and secondary ICD9-CM diagnoses.ResultsThe medical record review identified 1273 acute ischemic stroke events. The hospital discharge records identified 898 among those (true-positive cases),but missed 375 events (false-negative cases), and identified 104 events that were not eventually confirmed as acute ischemic events (false-positive cases). Code-group specific Positive Predictive Value was 85.7% (95%CI,74.6–93.3) for 433*1 and 89.9% (95%CI, 87.8–91.7) for 434*1 codes. Thrombolysis treatment, as identified by ICD9-CM code 99.10, was only documented in 6.0% of acute ischemic stroke events, but was 13.6% in medical record review.ConclusionsHospital discharge data were found to be fairly specific but insensitive in the reporting of acute ischemic stroke and thrombolysis, providing misleading indications about both quantity and quality of acute ischemic stroke hospital care. Efforts to improve coding accuracy should precede the use of hospital discharge data to measure hospital performances in acute ischemic stroke care.

Higher Incidence of Stroke on the Last Day of the Month in Hungary—a Role for Psychosocial Factors and Financial Insecurity?

The seasonal cumulation of acute ischemic stroke events is a well-known phenomenon. Critical days are determined by both biological and psychosocial factors. We hypothesized that the financial stability of those with a monthly income living in an economically unpredictable environment rises upon the arrival of their salary and decreases in the preceding days, leading to anxiety and existential insecurity, which may increase the incidence of acute ischemic stroke. We assessed the daily average number of thrombolytic treatments due to acute ischemic stroke in Hungary between December 1, 2005, and November 30, 2013, calculating the ratio of thrombolytic treatments on the last day of the month (irrespectively whether it was the 28th-31st days) to thrombolytic treatments on the other days, and determined 95% confidence intervals. In this period, 7880 thrombolytic treatments were performed nationwide (2.70/day), out of which 1867 occurred on the last day of the month (19.45/day). If the 28th, 29th, or 30th was not the last day of the month, 15.8, 20.6, and 22 times less thrombolytic treatments, respectively, were performed than on the last day of that month. We propose that financial insecurity on the days prior to the receipt of a salary might play a role in the elevation of stroke incidence observed on the last day of the month in Hungary. Further analysis of this phenomenon and its psychosocial effects is needed to adequately allocate healthcare resources and to take preventive measures in the high-risk population.

Short- and longer-term health-care resource utilization and costs associated with acute ischemic stroke.

ObjectivesThe mean lifetime cost of ischemic stroke is approximately $140,048 in the United States, placing stroke among the top 10 most costly conditions among Medicare beneficiaries. The objective of this study was to describe the health-care resource utilization and costs in the year following hospitalization for acute ischemic stroke (AIS).MethodsThis retrospective claims analysis quantifies utilization and costs following inpatient admission for AIS among the commercially insured and Medicare beneficiaries in the Truven Health databases. Patients who were 18 years or older and continuously enrolled for 12 months before and after an AIS event occurring (index) between January 2009 and December 2012 were identified. Patients with AIS in the year preindex were excluded. Demographic and clinical characteristics were evaluated at admission and in the preindex, respectively. Direct costs, readmissions, and inpatient length of stay (LOS) were described in the year postindex.ResultsThe eligible populations comprised 20,314 commercially insured patients and 31,037 Medicare beneficiaries. Average all-cause costs were $61,354 and $44,929 (commercial and Medicare, respectively) in the first year after the AIS. Approximately 50%–55% of total 12-month costs were incurred between day 31 and day 365 following the incident AIS. One quarter (24.6%) of commercially insured patients and 38.8% of Medicare beneficiaries were readmitted within 30 days with 16.6% and 71.7% (commercial and Medicare, respectively) of those having a principal diagnosis of AIS. The average AIS-related readmission length of stay was nearly three times that of the initial hospitalization for both commercially insured patients (3.8 vs 10.8 days) and Medicare beneficiaries (4.0 vs 10.8 days).ConclusionIn addition to the substantial costs of the initial hospitalization of an AIS, these costs double within the year following this event. Given the high cost associated with AIS, new interventions reducing either the acute or longer-term burden of AIS are needed.

Prognostic significance of Ischemia Modified Albumin and role of high sensitive Creactive protein levels in acute ischemic stroke patients

Introduction: Acute ischemic stroke (AIS) is one of the leading cause of death worldwide and the main causes of long-term disability. Brain CT shows no abnormality in the early event of AIS and the infarct may not be seen reliably for 24-48 hours. Oxidative stress is proposed as a fundamental mechanism of brain damage in ischemic stroke. Earlier it was reported that free radicals alters the N-terminus of the albumin which decreases its binding capacity for metals and is termed as Ischemia Modified Albumin (IMA). Recently it was found that IMA is increased in cerebrovascular diseases and may serve as biomarker for early identification of acute stroke. There is little information regarding the use of IMA for the prognosis of AIS. There is growing evidence of the importance of high sensitive C-reactive protein (hs-CRP) in Acute Ischemic Stroke. Therefore, the current study aims to determine the prognostic evaluation of time course of serum level of IMA and hs-CRP in Acute ischemic Stroke patients. Material and Method: 56 AIS patients diagnosed (clinically/ radiologically) of either sex and >18 years of age were taken as cases. 56 age and sex matched healthy subjects were taken as controls. Serum IMA levels were estimated by spectrophotometric method and hs-CRP levels were estimated by Auto-analyzer. Results: There was a significant increase in IMA levels in AIS patients at the time of admission (488.82±24.84) and on 3rd day (397.17±32.44) when compared to control (324.27±36.45) group. It was found to be statistically significant (P < 0.001). There was a significant increase in Hs-CRP levels in AIS patients at the time of admission (9.55±1.63) than in control (0.95±0.40) group. It was found to be statistically significant (P < 0.001). Conclusion: Estimation of serum IMA in AIS patients has both diagnostic and prognostic application. Routine hs-CRP measurement will be a useful tool for identifying AIS patients, in order to plan aggre

Smoking Paradox in Patients Hospitalized With Coronary Artery Disease or Acute Ischemic Stroke

Smoking is a potent risk factor for coronary artery disease (CAD) and acute ischemic stroke (AIS), but there are numerous reports of lower in-hospital mortality among smokers versus nonsmokers hospitalized for these events. We analyzed all consecutive patients hospitalized with a first index CAD (n=158 054) or AIS (n=899 295) event in Get With The Guidelines from 2002 to 2012; 20.4% of AIS and 30.4% of patients with CAD were past-year smokers. Multivariable models and age-stratified analyses were used to estimate the adjusted odds ratio of in-hospital mortality in smokers versus nonsmokers. Smokers were younger, more often male, with fewer vascular risk factors, and were more likely to be admitted to hospitals that were large, academic, or in the South. In-hospital mortality was significantly lower among smokers in both CAD (2.7% versus 5.2%; P<0.0001) and AIS (3.5% versus 5.8%; P<0.0001). The difference between unadjusted and adjusted odds ratios for smoking (0.57 versus 0.86 in CAD; 0.56 versus 0.86 in AIS) indicates the presence of substantial confounding by age and other covariates, but a significant association of past-year smoking remained. Among patients hospitalized with CAD and AIS, smoking is a risk factor for early age of onset, even among those with few vascular risk factors. The persistent association with lower in-hospital mortality after adjusted and stratified analyses probably represents residual unmeasured confounding, although a biological effect of smoking cannot be excluded. Further clinical and prospective population-based studies are needed to explore variables that contribute to outcomes in these patients.

Temperature Management and Nursing Care of the Patient With Acute Ischemic Stroke.

The term targeted temperature management (TTM) encompasses both induced hypothermia and fever reduction (normothermia).1,2 For patients with acute ischemic stroke (AIS), the use of TTM has been increasingly explored as a form of neuroprotection.3–5 The growing body of TTM literature provides pathophysiologic evidence but does not specifically provide evidence to address the role of the nurse.6 Therefore, the purpose of this review is to provide a summary of the current state of the evidence for TTM nursing care of the patient with AIS. Although thrombolytic therapy (tissue-type plasminogen activator [tPA]) and mechanical thrombectomy are associated with improved outcome for AIS, a large percent of patients are unable to receive tPA based on various exclusion criteria.7 Recent estimates indicate that <30% of eligible patients receive tPA.8 So, there are ≈565 000 patients for whom neuroprotection will be a primary strategy. Before the use of intravenous tPA, there were few therapeutic options to treat the vascular cause (blocked arterial blood flow) of an AIS event.6 Thus, throughout the majority of the 20th century, nursing research focused on stroke prevention and subsequent rehabilitation after AIS.6 With tPA, and now mechanical thrombectomy, the focus has shifted toward early intervention to restore blood flow. However, restoring flow to the penumbra is only part of the solution because neurons have to recover. Evidence suggests that in patients with stroke or other brain injuries, fever is associated with worse outcomes, leading to higher mortality rate, disability, loss of function, and longer hospital stay.9 In response, cooling was developed as a neuroprotection for ischemic cerebral tissues. Cheung et al10 did systematic review of randomized …

The expression of CD40 and matrix metalloproteinase in canotid endarterectomy plaques and the study of plaque stability

Objective To study the expression level of CD40 and matrix metalloproteinase (MMPs) in vulnerability, stability carotid atherosclerotic plaque. Investigate the relevance of CD40 and MMPs expression and the impact on plaque stability. Methods Thirty-two cases of specimens with carotid atherosclerotic plaque were collected from carotid endarterectomy(CEA). According to preoperative carotid ultrasound, transcranial doppler (TCD) and the presence of acute ischemic stroke events, all specimens were divided into stable plaque group and vulnerable plaque group, detected the mRNA and protein expression level of CD40 and MMPs in each group using PCR and western blotting assay. Results The mRNA and protein expression level of CD40 and MMP-9 in vulnerable plaque group was significantly higher than in stable plaque group respectively(P<0.01). The MMP-2 protein expression level in vulnerable plaque group was distinctly higher than in stable plaque group(P<0.01). There were positive correlation between CD40 mRNA and MMP-2 mRNA (r=0.43, P<0.05), CD40 mRNA and MMP-9 mRNA (r=0.90, P<0.01) respectively. Conclusion CD40 is not only involved in the formation of atherosclerotic plaque, but also may influence the stability of atherosclerotic plaques by regulating the expression of MMP-2 and MMP-9. Key words: Carotid endarterectomy; Atherosclerosis; Plaque stability; Antigens, CD40; Matrix metalloproteinases

Lack of Association between Family History of Stroke and 1‐year Outcomes after Acute Ischemic Stroke in Chinese

Lack of Association between Family History of Stroke and 1‐year Outcomes after Acute Ischemic Stroke in Chinese

Ischemic stroke

Stroke is a leading cause of severe, long-term disability and the third leading cause of death in the United States, affecting more than 700,000 people yearly.1 Clinic- and population-based studies have documented the role of traditional and novel risk factors.1,–,3 Most are traits, chronic conditions, or behaviors that affect the risk of stroke following many years of exposure. Less is known about potential triggers of stroke in the period immediately preceding stroke onset, such as physical exercise, drug use, and intake of alcohol or coffee. Coffee is of particular interest because of its widespread use. Consumption in some countries exceeds 10 kilograms per person per year, which corresponds to more than 100 g of pure caffeine per year. Caffeine may well be the most widely consumed drug in the world,4 but coffee consumption is socially acceptable and is generally thought to be a safe habit. In this issue of Neurology ®, Mostofsky and colleagues5 challenge the idea of coffee being safe. They test the hypothesis that coffee intake is associated with a transient increase in risk of ischemic stroke. In a multicenter case-crossover study, they studied 390 subjects after an acute ischemic stroke event. Each subject's coffee consumption in the hour before stroke …

Seasonal Variation in Ischemic Stroke Incidence and Association with Climate: A Six‐Year Population‐Based Study

Questions about the seasonality of stroke remain controversial. Using a nationwide population‐based dataset, this study presents a time series analysis of seasonal patterns in ischemic stroke occurrence, along with their association with climate in Taiwan. Using data from the Taiwan National Health Insurance Research Database, a total of 168,977 visits to emergency departments between 1998 and 2003 for ischemic stroke were identified for patients ranging between 20 and 84 yrs of age. Monthly stroke incidences were calculated for 72 months, by sex and stroke subtype, and for the age groups 20–54, 55–64, 65–74, and ≥75 yrs per 100,000 of the population. We performed auto‐regressive integrated moving average (ARIMA) analysis to investigate the presence of seasonality and any association with climate for acute ischemic stroke events. We found no significant seasonal variation in the incidence of ischemic stroke for any age or sex groups. Furthermore, after adjusting for seasonality, month, and trend, the ARIMA regression model revealed only associations between ischemic stroke incidence and atmospheric pressure. We conclude that seasonality of ischemic stroke does not exist in Taiwan. Ischemic stroke incidence is, however, significantly related to atmospheric pressure.

Multiple infections in carotid atherosclerotic plaques

Background Chlamydia pneumoniae , cytomegalovirus, herpes simplex virus, and recently, periodontal disease, have been associated with human atherosclerosis. Porphyromonas gingivalis and Streptococcus sanguis are major pathogens associated with periodontitis, a common chronic inflammatory condition in adults. Investigators have found that these infectious agents may influence vascular cell functions by inducing thrombus formation, vascular cell proliferation, apoptosis, and cell death. Methods and Results The main purpose of our study was to investigate the relation between the presence of multiple infectious agents in human carotid endarterectomy specimens and pathoanatomic features of the corresponding carotid plaques. Histologically, plaque rupture of the fibrous cap and communication of the luminal thrombus with the central necrotic lipid core was seen in or at proximity to the macrophage-rich shoulder (unstable plaque region). Thrombus within the lipid core without plaque rupture was occasionally found near the internal elastic lamina, associated with increased vascularity and lymphocytic infiltrate. Apoptosis, as detected by both the immunohistochemical staining of apoptosis-related proteins and in situ labeling of internucleosomally degraded DNA, was common in atherosclerotic plaques. Immunostainings for C pneumoniae , cytomegalovirus, herpes simplex virus-1, P gingivalis, and S sanguis were positive in the carotid plaques. From 1 to 4 organisms were found in the same specimen. The micro-organisms were immunolocalized in plaque shoulders and lymphohistiocytic infiltrate, associated with ulcer and thrombus formation, and adjacent to areas of strong labeling for apoptotic bodies. Conclusions Our data provide evidence that multiple infectious agents may be found in atherosclerotic plaques, and sometimes in the same specimen. The current study is the first to report the detection of 2 major odontopathogens, P gingivalis and S sanguis, in atherosclerotic plaques. The immunolocalization of these micro-organisms within unstable plaque regions and their association with plaque ulceration, thrombosis, and apoptosis in vascular cells are intriguing. Multiple infectious agents may alter vascular cell function and provide a “trigger” for acute ischemic stroke events. Further evidence from human studies and animal models will be needed. (Am Heart J 1999;138:S534-S536.)