Stroke Unit Care Research Articles

Effect of admission in the stroke care unit versus intensive care unit on in-hospital mortality in patients with acute ischemic stroke

Background/objectiveFew reports have directly compared the outcomes of patients with acute ischemic stroke (AIS) who are managed in a stroke care unit (SCU) with those who are managed in an intensive care units (ICU). This large database study in Japan aimed to compare in-hospital mortality between patients with AIS admitted into SCU and those admitted into ICU.MethodsPatients with AIS who were admitted between April 1, 2014, and March 31, 2019, were selected from the administrative database and divided into the SCU and ICU groups. We calculated the propensity score to match groups for which the admission unit assignment was independent of confounding factors, including the modified Rankin scale (mRS) score. The primary outcome was in-hospital mortality, and secondary outcomes were the mRS score at discharge, length of stay (LOS), and total hospitalization cost.ResultsOverall, 8,683 patients were included, and 960 pairs were matched. After matching, the in-hospital mortality rates of the SCU and ICU groups were not significantly different (5.9% vs. 7.9%, P = 0.106). LOS was significantly shorter (SCU = 20.9 vs. ICU = 26.2 days, P < 0.001) and expenses were significantly lower in the SCU group than in the ICU group (SCU = 1,686,588 vs. ICU = 1,998,260 yen, P < 0.001). mRS scores (score of 1–3 or 4–6) at discharge were not significantly different after matching. Stratified analysis showed that the in-hospital mortality rate was lower in the ICU group than in the SCU group among patients who underwent thrombectomy.ConclusionsIn-hospital mortality was not significantly different between the ICU and SCU groups, with significantly lower costs and shorter LOS in the SCU group than in the ICU group.

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis

Stroke unit care provides substantial benefits for all subgroups of patient with stroke, but consistent access has been difficult to achieve in many healthcare systems. Pay-for-performance incentives have been introduced widely in attempt to improve quality and efficiency in healthcare, but there is limited evidence of positive impact when they are targeted at hospitals. In 2012, a pay-for-performance program targeting stroke unit access was co-designed and implemented within a clinical quality improvement network across public hospitals in Queensland, Australia. We assessed the impact on access to specialist care and mortality following stroke. We used interrupted time series analysis on linked hospital and death registry data to compare changes in level (absolute proportions) and trends in outcomes (stroke/coronary care unit admission, 6-month mortality) for stroke, and a control condition of myocardial infarction (MI) without pay-for-performance incentive, from 2009 before, to 2017 after introduction of the pay-for-performance scheme in2012. We included 23,572 patients with stroke and 39,511 with MI. Following pay-for-performance introduction, stroke unit access increased by an absolute 35% (95% CI 29, 41) more than historical trend prediction, with greater impact for regional/rural residents (41% vs major city 24%) where baseline access was lowest (18% vs major city residents 53%). Historical upward 6-month mortality trends following stroke (+0.11%/month) reversed to a downward slope (-0.05%/month) with pay-for-performance; difference-0.16%/month (95% CI-0.29,-0.03). In contrast, access to coronary care and mortality trends for MI controls were unchanged, difference-in-difference for mortality-0.18%, (95% CI-0.34,-0.02). This clinician led pay-for-performance incentive stimulated significant improvements in stroke unit access, reduced regional disparities; and resulted in a sustained decline in 6-month mortality. As our findings contrast with lack of effect in most hospital directed pay-for-performance programs, differences in design and context provide insights for optimal program design. Queensland Advancing Clinical Research Fellowship, National Health and Medical Research Council Senior Research Fellowship.

Stroke epidemiology and outcomes of stroke patients in Nepal: a systematic review and meta-analysis

BackgroundWith an increasing burden of stroke, it is essential to minimize the incidence of stroke and improve stroke care by emphasizing areas that bring out the maximum impact. The care situation remains unclear in the absence of a national stroke care registry and a lack of structured hospital-based data monitoring. We conducted this systematic review and meta-analysis to assess the status of stroke care in Nepal and identify areas that need dedicated improvement in stroke care.MethodsA systematic literature review was conducted to identify all studies on stroke epidemiology or stroke care published between 2000 and 2020 in Nepal. Data analysis was done with Statistical Package for Social Sciences (SPSS) and Comprehensive Meta-analysis (CMA-3).ResultsWe identified 2533 studies after database searching, and 55 were included in quantitative and narrative synthesis. All analyses were done in tertiary care settings in densely populated central parts of Nepal. Ischemic stroke was more frequent (70.87%) than hemorrhagic (26.79%), and the mean age of stroke patients was 62,9 years. Mortality occurred in 16.9% (13-21.7%), thrombolysis was performed in 2.39% of patients, and no studies described thrombectomy or stroke unit care.ConclusionThe provision of stroke care in Nepal needs to catch up to international standards, and our systematic review demonstrated the need to improve access to quality stroke care. Dedicated studies on establishing stroke care units, prevention, rehabilitation, and studies on lower levels of care or remote regions are required.

Nursing Care for Stroke Patients: Current Practice and Future Needs.

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Stroke nurses play an important role in the care of patients living with stroke by using best practices and adhering to stroke-management guidelines. This study aims at examining the current nursing practice for stroke patients in Saudi Arabia. A cross-sectional descriptive design was used to collect data from nurses working in the stroke unit and intensive care unit between the period of February and June 2022 using electronic self-administered questionnaires. A convenience sample of 131 nurses who provided care for stroke patients was enrolled. Significant differences in nursing practice were found between the stroke units and the intensive care units regarding the activation of the stroke code, X2 (4, N = 131) = 48.34, p < 0.001; transferring stroke patients to a designated bed, X2 (4, N = 131) = 48.74, p = 0.002; applying the NIHSS, X2 (4, N = 131) = 70.11, p < 0.001; using the modified Rankin scale, X2 (4, N = 131) = 61.24, p < 0.001; providing intervention for neglect syndrome, X2 (4, N = 131) = 44.72, and hemianopsia, X2 (4, N = 131) = 39.22; screening for poststroke depression, X2 (4, N = 131) = 101.59, p < 0.001; assessing for psychosocial needs, X2 (4, N = 131) = 74.44, p < 0.001, and encouraging patients to express their feelings, X2 (4, N = 131) = 58.64, p < 0.001; educating patients and families about stroke prevention, X2 (4, N = 131) = 40.51, p < 0.001. As per the results of the study, there is an urgent need for stroke units run by specialized stroke nurses to provide early stroke management and improve survivors' outcomes. Structured stroke-care programs are needed to improve nursing practice and meet the international standard of stroke care.

Fracture Risk Increases After Stroke or Transient Ischemic Attack and Is Associated With Reduced Quality of Life.

Fractures are a serious consequence following stroke, but it is unclear how these events influence health-related quality of life (HRQoL). We aimed to compare annualized rates of fractures before and after stroke or transient ischemic attack (TIA), identify associated factors, and examine the relationship with HRQoL after stroke/TIA. Retrospective cohort study using data from the Australian Stroke Clinical Registry (2009-2013) linked with hospital administrative and mortality data. Rates of fractures were assessed in the 1-year period before and after stroke/TIA. Negative binomial regression, with censoring at death, was used to identify factors associated with fractures after stroke/TIA. Respondents provided HRQoL data once between 90 and 180 days after stroke/TIA using the EuroQoL 5-dimensional 3-level instrument. Adjusted logistic regression was used to assess differences in HRQoL at 90 to 180 days by previous fracture. Among 13 594 adult survivors of stroke/TIA (49.7% aged ≥75 years, 45.5% female, 47.9% unable to walk on admission), 618 fractures occurred in the year before stroke/TIA (45 fractures per 1000 person-years) compared with 888 fractures in the year after stroke/TIA (74 fractures per 1000 person-years). This represented a relative increase of 63% (95% CI, 47%-80%). Factors associated with poststroke fractures included being female (incidence rate ratio [IRR], 1.34 [95% CI, 1.05-1.72]), increased age (per 10-year increase, IRR, 1.35 [95% CI, 1.21-1.50]), history of prior fracture(s; IRR, 2.56 [95% CI, 1.77-3.70]), and higher Charlson Comorbidity Scores (per 1-point increase, IRR, 1.18 [95% CI, 1.10-1.27]). Receipt of stroke unit care was associated with fewer poststroke fractures (IRR, 0.67 [95% CI, 0.49-0.93]). HRQoL at 90 to 180 days was worse among patients with prior fracture across the domains of mobility, self-care, usual activities, and pain/discomfort. Fracture risk increases substantially after stroke/TIA, and a history of these events is associated with poorer HRQoL at 90 to 180 days after stroke/TIA.

IMPETUS Stroke: Assessment of hospital infrastructure and workflow for implementation of uniform stroke care pathway in India.

India accounts for 13.3% of global disability-adjusted life years (DALYs) lost due to stroke with a relatively younger age of onset compared to the Western population. In India's public healthcare system, many stroke patients seek care at tertiary-level government-funded medical colleges where an optimal level of stroke care is expected. However, there are no studies from India that have assessed the quality of stroke care, including infrastructure, imaging facilities, or the availability of stroke care units in medical colleges. This study aimed to understand the existing protocols and management of acute stroke care across 22 medical colleges in India, as part of the baseline assessment of the ongoing IMPETUS stroke study. A semi-structured quantitative pre-tested questionnaire, developed based on review of literature and expert discussion, was mailed to 22 participating sites of the IMPETUS stroke study. The questionnaire assessed comprehensively all components of stroke care, including human resources, emergency system, in-hospital care, and secondary prevention. A descriptive analysis of their status was undertaken. In the emergency services, limited stroke helpline numbers, 3/22 (14%); prenotification system, 5/22 (23%); and stroke-trained physicians were available, 6/22 (27%). One-third of hospitals did not have on-call neurologists. Although non-contrast computed tomography (NCCT) was always available, 39% of hospitals were not doing computed tomography (CT) angiography and 13/22 (59%) were not doing magnetic resonance imaging (MRI) after routine working hours. Intravenous thrombolysis was being done in 20/22 (91%) hospitals, but 36% of hospitals did not provide it free of cost. Endovascular therapy was available only in 6/22 (27%) hospitals. The study highlighted the scarcity of multidisciplinary stroke teams, 8/22 (36%), and stroke units, 7/22 (32%). Lifesaving surgeries like hematoma evacuation, 11/22 (50%), and decompressive craniectomy, 9/22 (41%), were performed in limited numbers. The availability of occupational therapists, speech therapists, and cognitive rehabilitation was minimal. This study highlighted the current status of acute stroke management in publicly funded tertiary care hospitals. Lack of prenotification, limited number of stroke-trained physicians and neurosurgeons, relatively lesser provision of free thrombolytic agents, limited stroke units, and lack of rehabilitation services are areas needing urgent attention by policymakers and creation of sustainable education models for uniform stroke care by medical professionals across the country.

The early impact of COVID-19 pandemic on mobile stroke unit care delivery: A worldwide survey

ObjectiveTo report COVID −19 pandemic impact on mobile stroke units (MSUs) a world-wide survey of MSU programs. MethodsContact information of MSU program was obtained through the Pre-hospital Stroke Treatment Organization. Anonymous electronic questionnaire was developed and sent through the email to one representative of each program on May 15, 2020. ResultsOf 26 programs queried, 20 responded and completed survey based on the data or personal impression. Eighteen programs were in the regions with pandemic lockdown. Six either suspended or reduced MSU availability at some point. The reasons given for change in availability were as follows: decreased personnel availability (5 programs), risk of exposure (5 programs), and financial concerns (1 program). Staff availability was a concern among 8 programs. MSU activations were reported to be unchanged by 10 programs, but 9 programs experienced decline in activation, 1 program had more activations. Sixteen programs reported change in MSU protocol including introduction of screening questionnaire, PPE, reducing patient contact, and cleaning protocols. Nine reported that the crew was under greater stress. Only 2 respondents felt that the pandemic delayed stroke care on MSU and the remainder did not. ConclusionOverall Stroke care delivery had no major disruptions despite COVID 19 pandemic posed challenges to MSU Operations.

Datawarehouse-enabled quality control of atrial fibrillation detection in the stroke unit setting

Objective(1) To assess the accuracy of a standard operating procedure (SOP) regarding the utilization of atrial fibrillation (AF) alarms in everyday clinical practice, and (2) to evaluate the performance of automated continuous surveillance for atrial fibrillation (AF) in hospitalized acute stroke patients. DesignRetrospective cohort study. SettingTwo stroke units from two tertiary care hospitals in Berlin, Germany. ParticipantsWe identified 635 patients with ischemic stroke diagnosis for the time period between 01. January and 30. September 2021 of which 176 patients had recorded AF alarms during monitoring. Of those, 115 patients were randomly selected for evaluation. After excluding 6 patients with hemorrhagic stroke in their records, 109 patients (mean age: 79.1 years, median NIHSS at admission: 6, 57% female) remained for analysis. InterventionUsing a clinical data warehouse for comprehensive data storage we retrospectively downloaded and visualized ECG data segments of 65 s duration around the automated AF alarms. We restricted the maximum number of ECG segments to ten per patient. Each ECG segment plot was uploaded into a REDCap database and categorized as either AF, non-AF or artifact by manual review. Atrial flutter was subsumed as AF. These classifications were then matched with 1) medical history and known diseases before stroke, 2) discharge diagnosis, and 3) recommended treatment plan in the medical history using electronic health records. Main outcome measuresThe primary outcome was the proportion of previously unknown AF diagnoses correctly identified by the monitoring system but missed by the clinical team during hospitalization. Secondary outcomes included the proportion of patients in whom a diagnosis of AF would likely have led to anticoagulant therapy. We also evaluated the accuracy of the automated detection system in terms of its positive predictive value (PPV). ResultsWe evaluated a total of 717 ECG alarm segments from 109 patients. In 4 patients (3.7, 95% confidence interval [CI] 1.18–9.68%) physicians had missed AF despite at least one true positive alarm. All four patients did not receive long-term secondary prevention in form of anticoagulant therapy. 427 out of 717 alarms were rated true positives, resulting in a positive predictive value of 0.6 (CI 0.56–0.63) in this cohort. ConclusionBy connecting a data warehouse, electronic health records and a REDCap survey tool, we introduce a path to assess the monitoring quality of AF in acute stroke patients. We find that implemented standards of procedure to detect AF during stroke unit care are effective but leave room for improvement. Such data warehouse-based concepts may help to adjust internal processes or identify targets of further investigations.

Delivery of acute ischaemic stroke treatments in the European region in 2019 and 2020.

We assessed best available data on access and delivery of acute stroke unit (SU) care, intravenous thrombolysis (IVT) and endovascular treatment (EVT) in the European region in 2019 and 2020. We compared national data per number of inhabitants and per 100 annual incident first-ever ischaemic strokes (AIIS) in 46 countries. Population estimates and ischaemic stroke incidence were based on United Nations data and the Global Burden of Disease Report 2019, respectively. The estimated mean number of acute SUs in 2019 was 3.68 (95% CI: 2.90-4.45) per one million inhabitants (MIH) with 7/44 countries having less than one SU per one MIH. The estimated mean annual number of IVTs was 21.03 (95% CI: 15.63-26.43) per 100,000 and 17.14% (95% CI: 12.98-21.30) of the AIIS in 2019, with highest country rates at 79.19 and 52.66%, respectively, and 15 countries delivering less than 10 IVT per 100,000. The estimated mean annual number of EVTs in 2019 was 7.87 (95% CI: 5.96-9.77) per 100,000 and 6.91% (95% CI: 5.15-8.67) of AIIS, with 11 countries delivering less than 1.5 EVT per 100,000. Rates of SUs, IVT and EVT were stable in 2020. There was an increase in mean rates of SUs, IVT and EVT compared to similar data from 2016. Although there was an increase in reperfusion treatment rates in many countries between 2016 and 2019, this was halted in 2020. There are persistent major inequalities in acute stroke treatment in the European region. Tailored strategies directed to the most vulnerable regions should be prioritised.

Timing of Initiation of Acute Stroke Rehabilitation and Management Corresponding to Complications at Primary Stroke Centers in Japan: A Nationwide Cross-Sectional Web-Based Questionnaire Survey

Introduction: Many guidelines now recommend early rehabilitation for acute stroke patients. However, evidence remains lacking regarding the specific timings for initiation of various rehabilitation steps and management when complications are encountered in acute stroke rehabilitation. This survey aimed to investigate actual clinical situations in acute stroke rehabilitation in Japan and to improve the medical systems for rehabilitation and plan further studies. Methods: This nationwide, cross-sectional, web-based questionnaire survey was administered between February 7, 2022, and April 21, 2022, targeting all primary stroke centers (PSCs) in Japan. Among several components of the survey, this paper focused on the timing of the initiation of three rehabilitation steps (passive bed exercise; head elevation; and out-of-bed mobilization), along with the management of rehabilitation (continued or suspended) in the event of complications during acute stroke rehabilitation. We also investigated the influence of facility features on these contents. Results: Responses were obtained from 639 of the 959 PSCs surveyed (response rate: 66.6%). In cases of ischemic stroke and intracerebral hemorrhage, most PSCs initiated passive bed exercise on day 1, head elevation on day 1, and out-of-bed mobilization on day 2 (with day of admission defined as day 1). In cases with subarachnoid hemorrhage, rehabilitation steps were delayed compared to other stroke subtypes or showed wide variation depending on the facility. Passive bed exercise was accelerated by the presence of protocols for rehabilitation and weekend rehabilitation. Out-of-bed mobilization was accelerated by the presence of a stroke care unit. Facilities with board-certified rehabilitation doctors were cautious regarding the initiation of head elevation. Most PSCs suspended rehabilitation training in the event of symptomatic systemic/neurological complications. Conclusion: Our survey revealed the actual situation of acute stroke rehabilitation in Japan and indicated that some facility features appear to influence early increases in physical activity levels and early mobilization. Our survey provides fundamental data to improve the medical systems for acute stroke rehabilitation in the future.

The Effect of Mobile Stroke Unit Care on Functional Outcomes: An Application of the Front-door Formula.

The Berlin-based B_PROUD study was designed to assess the effect of mobile stroke unit (MSU) dispatch among ischemic stroke and transient ischemic attack (TIA) patients without contraindications to reperfusion treatments. However, a large proportion of patients for whom the MSU was dispatched did not ultimately receive MSU care. We estimated the causal effect of additional MSU care on 3-month functional outcomes among B_PROUD patients for whom an MSU was dispatched. We used data from the B_PROUD study (1 February 2017-8 May 2019). Given the presence of exposure-outcome unmeasured confounding, we used the front-door formula to identify the distribution of modified Rankin scale (mRS) outcomes under two hypothetical interventions: (1) receiving additional MSU care and (2) only receiving conventional care. We considered the time from dispatch to thrombolysis as the full mediator and adjusted for exposure-mediator and mediator-outcome confounding. We used a parametric estimator to estimate the common odds ratio (cOR) and 95% bootstrapped confidence intervals (CI). We included in total 768 ischemic stroke/TIA patients with MSU dispatch. The MSU was canceled for 180 (23%) patients, whereas 588 (77%) received MSU care. The unadjusted association between the care group and mRS favored conventional care (cOR = 1.7; 95% CI = 1.2, 2.3); however, after applying the front-door formula, the mRS distribution favored MSU care (cOR = 0.88; 95% CI = 0.81, 0.96). Receiving MSU care was associated with better functional outcomes than conventional care only, compatible with the hypothesized beneficial effect of MSU care on poststroke outcomes, among stroke and TIA patients without contraindications to reperfusion treatments.

Pre-existing sarcopenia and swallowing outcomes in acute stroke patients

This study aimed to investigate the associations of pre-existing sarcopenia with swallowing function, oral intake level, and aspiration pneumonia in patients with acute stroke. This observational study included patients (≥60 years of age) with acute ischemic stroke or intracerebral hemorrhage within 7 days of onset who were screened for sarcopenia, malnutrition, and swallowing difficulties in a stroke-care unit within 48h of admission. Sarcopenia was defined by the Asian Working Group on Sarcopenia 2019 as having a low calf circumference, handgrip strength, and appendicular muscle mass index. The primary outcome was impaired oral intake (functional oral intake scale <5 points) at 3, 7, and 14 days after admission, and the secondary outcome was aspiration pneumonia during hospitalization. We enrolled 350 patients (median age of 77 years; 63% males) who underwent the aforementioned screening. Sarcopenia was diagnosed in 34% of patients, and malnutrition was found in 66% of patients with sarcopenia. When compared with the comparison group (defined as patients with either or both normal calf circumference and handgrip strength), the sarcopenia group had significantly lower tongue pressure and a higher prevalence of dysphagia. Sarcopenia was associated with functional oral intake scale <5at 7 days (adjusted odds ratio [OR], 4.72; 95% confidence interval [CI], 1.91-11.71); p=0.002) and 14 days (adjusted OR, 3.93; 95% CI, 1.47-10.53; p=0.006) and with aspiration pneumonia during hospitalization (adjusted OR, 6.12; 95% CI, 1.63-22.94; p=0.007). Acute stroke patients with sarcopenia may have weakness of the swallowing-related muscles which may lead to impaired oral intake and aspiration pneumonia.

Accuracy of real time heart rate monitoring using smartwatch in a stroke care unit

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ISCIII Smartwatch with heart rate (HR) tracker measures may allow for identification of people with high resting HR who have a higher risk of atrial fibrillation (AF), a potent independent risk factor for embolic strokes. In this research, we propose a new protocol for collecting real time data of patients with cryptogenic stroke including HR at rest along with monitoring electrocardiogram (ECG). First, we assess the concordance of HR measurement between telemetry (TLM) and two smartwatches in acute stroke patients, as well as the determinants of measurement error. Method We included patients over 50 years of age hospitalized in our Stroke Unit who were monitored by TLM and used the Garmin Vivosmart HR® (S1) and Fitbit Charge 5® (S2) devices. Mean HR was collected at 5, 10, 15, 20, and 25 minutes. We applied the Bland-Altman method in combination with Lin's Concordance Correlation Coefficient (CCC) to assess agreement between measurements. A coefficient CCC &amp;gt; 0.9 indicates acceptable agreement. Results The experimental setup was performed using 49 stroke patients (59% women, mean age 78 ± 9.86 years, and 69% with a history of AF). Poor agreement was observed between HR measurements by SI or S2 and TLM (CCC = 0.48 and 0.57 respectively), which was conditioned by the presence of AF during the measurement (CCC = -0.17 and -0.06). There was only good concordance in the absence of AF (CCC = 0.97 and 0.92). A higher percentage of error between measurements was significantly associated with a HR &amp;gt; 90 bpm, a history of AF, or presenting AF during the measurement (p&amp;lt;0.001). Conclusions Real-time monitoring of HR at rest in each smartwatch was not accurate in acute stroke patients who had presented AF during the intake, or when HR by TLM was greater than 90. This suggests certain limitations when considering the application of processed data from this wearable technology.

Investigation of the Frequency of Insulin Use Compared to Other Anti-diabetic Drugs in Diabetic Patients Presenting Acute Stroke

Background: This study aimed to measure the frequency of insulin use, compared to other antidiabetic drugs, in diabetic patients presenting with acute stroke in order to investigate its effect on the incidence of stroke. Methods: All diabetic patients with acute stroke who were referred to the emergency department within one year were included in this retrospective descriptive-analytic study. The collected data were statistically analyzed using SPSS 20. Data were reported as descriptive statistics (frequency and percentage) and means (±SD). Non-independent t test and chi-square test were used to compare quantitative and qualitative variables, respectively (P=0.05). Results: Out of 896 patients admitted to the stroke care unit, 191 cases were diagnosed with diabetes mellitus (DM). Computerized tomography (CT) scan findings performed in the emergency department represented about 30% of hemorrhagic results. There was a significant relationship between the type of diabetes treatment and the age of the patients, the CT scan findings, and the duration of DM in the patients. Conclusion: Therefore, patients with long-term involvement with diabetes and patients with high creatinine, due to insulin use, are discharged from hospitals with better conditions.

Addressing the Health Disparities in Acute Ischemic Stroke Outcomes in Africa (P7-5.011)

<h3>Objective:</h3> The purpose of this study is to discuss the burden of acute ischemic stroke in Africa, as well as how health care systems have attempted to reduce the disease’s incidence and improve outcomes. <h3>Background:</h3> Acute ischemic stroke is one of the leading causes of disability and mortality worldwide, and its prevalence is increasing in Africa, which is already plagued by infectious diseases. Rapid diagnosis and treatment are critical, as even minor delays in reperfusing the brain have a significant impact on recovery. In specialized stroke care units, neuroimaging is critical for optimal care and thrombolytic or endovascular therapy. <h3>Design/Methods:</h3> Data were gathered using the online databases PubMed, Ovid MEDLINE, ScienceDirect, and Embase. All articles on acute ischemic stroke in Africa were reviewed. <h3>Results:</h3> The medical care for acute ischemic stroke is far from optimal in Africa, with little adherence to recommended protocols. Due to a lack of funding, there is a lack of public awareness of the disease, imaging infrastructure, personnel, stroke care units, and recovery facilities. Inadequate knowledge of stroke signs and symptoms leads to treatment delays and a poor prognosis. <h3>Conclusions:</h3> We urge African leaders and private entities to invest in stroke care by constructing appropriate infrastructure, providing medical equipment, and putting in place guidelines and long-term follow-up systems. Telehealth is one proposed strategy to address the shortage of health personnel, and international and national efforts to increase treatment affordability should be increased. It is encouraged that more extensive research on the impact of acute ischemic stroke on the African population be conducted. <b>Disclosure:</b> Mr. Uwishema has nothing to disclose. Abdelmonem Siddiq has nothing to disclose.

Liver toxicity of intravenous heparin treatment in patients with acute ischemic stroke

ObjectiveSerum alanine aminotransferase (ALT), which is an indicator of liver dysfunction, may increase during treatment in patients in the acute phase of stroke. However, the cause of the ALT elevation is unclear, as multiple medications are often being used. We investigated the relationship between medications used in acute ischemic stroke, including cerebral infarction and transient ischemic attack, and ALT elevation. MethodsThe subjects were 230 patients who had been diagnosed with cerebral infarction or TIA and treated at the Stroke Care Unit of Fukuoka University Hospital. We investigated ALT abnormalities that occurred from the start of the treatment over the subsequent 14 days. We also followed patients for an additional seven days to confirm the peak ALT levels. A binomial logistic regression analysis was performed to evaluate the association between medications used during the period and ALT elevation. ResultsThe incidence of ALT abnormality was 23.9% (55/230). ALT elevation was mostly mild and peaked within 21 days of treatment initiation in 93.2% of the patients, excluding indeterminate patients. A binary logistic regression analysis showed that unfractionated heparin (odds ratio [OR] 2.759, 95% confidence interval [CI] 1.328–5.729, p = 0.007) was extracted as a cause of ALT elevation. In a receiver operating characteristic (ROC) analysis for the administration period of unfractionated heparin, the cut-off value (area under the ROC curve) for ALT elevation was 6 days (0.575). Significant factors contributing to ALT elevation caused by unfractionated heparin included an unfractionated heparin administration period of ≥ 6 days (OR 2.951, 95% CI 1.244–7.000, p = 0.014) and edaravone combination (OR 2.594, 95% CI 1.159–5.808, p = 0.021). ConclusionIn the acute phase of stroke, we believe that unfractionated heparin discontinuation is not necessary when hepatotoxicity of unfractionated heparin is suspected. However, physicians should be aware of the risk of liver toxicity when unfractionated heparin is administered for more than six days or when edaravone is used in combination.

Abstract WP6: Strokes Averted by Intravenous Thrombolysis: A Secondary Analysis of the BEST-MSU Trial

Introduction: While the goal of IV tissue plasminogen activator (TPA) is to prevent infarction, few data exist on averted stroke. Methods: Secondary analysis of a multicenter trial from 2014-2020 comparing outcomes between patients treated for stroke by mobile stroke unit (MSU) vs standard care (SC). The analytical cohort were patients with suspected stroke treated with IV TPA. The primary outcome was a time-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours. The secondary outcome was a tissue-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours and no acute infarction/hemorrhage on imaging. We used multivariable logistic regression to evaluate associations between study exposures (demographics, comorbidities, stroke characteristics) and outcomes. Results: Among 1009 patients with a median last known well-to-TPA time of 87 minutes, 276 patients (27%) had a time-defined averted stroke (31% MSU, 21% SC) and 159 patients (16%) had a tissue-defined averted stroke (18% MSU, 11% SC). Factors independently associated with time-defined averted stroke were younger age (OR, 0.98; 95% CI, 0.96-0.99), female sex (0R, 0.51; 95% CI, 0.36-0.74), hyperlipidemia (OR, 1.81, 95% CI, 1.24-2.64), normal premorbid function (0R, 2.22; 95% CI, 1.37-3.67), lower glucose (OR, 0.996; 95% CI, 0.993-0.999), lower MAP (OR, 0.991; 95% CI, 0.983-0.998), MSU care (OR, 1.77; 95% CI, 1.21-2.62), lower NIH stroke scale (OR, 0.89; 95% CI, 0.86-0.93), and no large vessel occlusion (LVO) (OR, 0.52; 95% CI, 0.32-0.83). For tissue-based averted stroke, younger age, female sex, hyperlipidemia, lower MAP, MSU treatment, lower NIH stroke scale, and no LVO were significantly associated. Conclusion: In a modern acute stroke trial, one-in-four patients treated with TPA for stroke recovered within 24 hours and one-in-six had no demonstrable brain injury on imaging. Younger age, female sex, hyperlipidemia, lower MAP, MSU care, lower stroke severity, and no LVO may increase the odds of averting stroke.

Abstract WMP7: Bridging Thrombolysis For Large Vessel Occlusion: Who Benefits Most? Analysis Of A Prospective Endovascular Therapy Registry

Introduction: Recent meta-analytic evidence supported efficacy and safety of bridging intravenous thrombolysis (IVT) prior to endovascular therapy (EVT) for large vessel occlusion (LVO) but large confirmatory trials are still lacking and optimal candidates for treatment have been a topic of contention lately. Objectives: We aimed to determine a cut-off in treatment times that allows identification of those who would benefit most from bridging IVT. Methods: We analyzed prospectively collected data from consecutive LVO patients who underwent EVT at a tertiary stroke center in Germany from 01/2017 to 12/2021. Patients underwent detailed cardiovascular phenotyping, repeated cranial imaging, and received standardized multidisciplinary stroke unit care. Functional outcome was assessed via modified Rankin scale three months after discharge. Ordinary ridge regression models were built to assess the impact of treatment time cut-offs on functional outcome with adjustment for age, sex, cardiovascular risk factors, baseline NIHSS, cerebrovascular territory, ASPECT score, stroke etiology and carotid artery stenting. Results: Out of 935 patients who had undergone EVT, 170 received bridging IVT (median age 74 [63-82, IQR], 52.4% females), fulfilled our criteria and were included in our analysis. Overall, onset-to-recanalization time but not onset-to-needle time was associated with functional outcome (β1=0.36, 95%CI [0.14,0.58], p=0.001 vs. p=ns). However, those who received EVT with a time delay longer than 190 minutes additionally displayed an association of onset-to-needle time and functional outcome (β1=0.64, 95%CI [0.25,1.04], p=0.02 vs. β2= 2.96, 95%CI [1.32,4.60], p=0.016). Conclusions: Our data indicates that the beneficial effect of swift bridging IVT on functional outcome is most pronounced in cases where initiation of subsequent EVT is substantially delayed.

Chronic anti-coagulation therapy reduced mortality in patients with high cardiovascular risk early in COVID-19 pandemic

BackgroundCoronavirus disease 2019 (COVID-19) is associated with provoked thrombo-inflammatory responses. Early in the COVID-19 pandemic this was thought to contribute to hypercoagulability and multi-organ system complications in infected patients. Limited studies have evaluated the impact of therapeutic anti-coagulation therapy (AC) in alleviating these risks in COVID-19 positive patients. Our study aimed to investigate whether long-term therapeutic AC can decrease the risk of multi-organ system complications (MOSC) including stroke, limb ischemia, gastrointestinal (GI) bleeding, in-hospital and intensive care unit death in COVID-19 positive patients hospitalized during the early phase of the pandemic in the United States.MethodsA retrospective analysis was conducted of all COVID-19 positive United States Veterans between March 2020 and October 2020. Patients receiving continuous outpatient therapeutic AC for a least 90 days prior to their initial COVID-19 positive test were assigned to the AC group. Patients who did not receive AC were included in a control group. We analyzed the primary study outcome of MOSC between the AC and control groups using binary logistic regression analysis (Odd-Ratio; OR).ResultsWe identified 48,066 COVID-19 patients, of them 879 (1.8%) were receiving continuous therapeutic AC. The AC cohort had significantly worse comorbidities than the control group. On the adjusted binary logistic regression model, therapeutic AC significantly decreased in-hospital mortality rate (OR; 0.67, p = 0.04), despite a higher incidence of GI bleeding (OR; 4.00, p = 0.02). However, therapeutic AC did not significantly reduce other adverse events.ConclusionAC therapy reduced in-hospital death early in the COVID-19 pandemic among patients who were hospitalized with the infection. However, it did not decrease the risk of MOSC. Additional trials are needed to determine the effectiveness of AC in preventing complications associated with ongoing emerging strains of the COVID-19 virus.

Stroke and endocarditis: Reversing the point of view. A retrospective, cohort study

Study objectivesThe primary objective of our study is to assess the endocarditis prevalence in patients admitted to the emergency department (ED) for a primary diagnosis of acute stroke (AS). Secondary objectives are the identification of early markers of endocarditis in AS patients and the analysis of the short-term outcome of this population. MethodsIn this observational, retrospective, cohort study we enrolled consecutive adult patients with a primary diagnosis of AS admitted to the Stroke Unit or to the Neurological Intensive Care Unit of our hospital who were then discharged with a diagnosis of endocarditis. These patients were then compared with age and sex-matched controls with a diagnosis of AS and atrial fibrillation. ResultsEndocarditis prevalence in patients admitted to the Stroke Unit or Neurological Intensive Care Unit with a primary diagnosis of AS is 1.0% (95% confidence interval 0.61-1.55). Fever on ED admission, concomitant cancer, low hemoglobin, low lymphocyte levels, a high neutrophils count and erythrocyte sedimentation levels could early differentiate among AS patients, those with endocarditis from those with atrial fibrillation. A moderate-to-severe valvular regurgitation is strongly suggestive of endocarditis. The short term-outcome is markedly worse in endocarditis patients compared to patients with atrial fibrillation, in terms of in-hospital mortality and discharge disability. ConclusionsEndocarditis prevalence in patients admitted for a primary diagnosis of AS is low, but this etiology leads to a poor outcome. Some laboratory, clinical-epidemiological and echocardiographic parameters may help the physician to early recognize this condition and, consequently, to promptly start an antibiotic therapy.