Chinese Stroke Center Alliance Research Articles

Intracerebral Hemorrhage Hematoma Expansion Prediction with Deep Learning

Background: Hematoma expansion (HE) is associated with poor clinical outcomes following intracerebral hemorrhage (IcH). Existing predictors of HE from non-contrast computed tomography (NCCT) have low sensitivity and high inter-observer variability. Availability of an objective, standardized method to predict HE remains an unmet need. Methods: This multicenter observational cohort study analyzed a retrospective dataset of 2350 patients (December 2011 to June 2018, NCCT only, 86 centers), and a prospective dataset of 460 patients (March 2018 to February 2019, NCCT plus clinical data, 28 centers) with acute IcH . Prediction of HE, defined as a hematoma growth of > 6ml within 48 hours was the primary outcome of the study. A deep learning system (DLS) was developed and validated to autonomously predict HE based on the NCCT images using retrospectively collected data. A multivariate logistic regression model and a five-point score based on clinical variables and DLS prediction score were then developed using prospectively collected data. Findings: The DLS, using only NCCT, achieved HE prediction AUC of 0·783 (95% CI, 0·693-0·871) on the prospective validation dataset. Multivariate analysis of clinical variables indicated a higher risk of HE in patients with higher baseline NIHSS (OR: 4·37(1·56-12·25)), shorter onset-to-NCCT time (OR: 2·92(1·13-7·56)), and lack of antihypertensive therapy history (OR: 2·61 (1·05-6·53)) . Inclusion of these clinical variables along with DLS prediction, further improved the HE prediction accuracy, achieving an AUC of 0·812 (0·732-0·891) which was higher than all the previous methods. Finally, an easy-to-use five-point score was developed, which achieved an AUC of 0·789 (0·707-0·871). Interpretation: Deep learning systems could provide an automated, objective, multicenter generalizable, and observer bias-free solution for HE prediction from NCCT images. Inclusion of clinical factors may further improve the prediction accuracy and the system can be used to identify patients at risk of HE leading to a personalized treatment planning. Funding: Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences, Beijing Municipal Committee of Science and Technology, Ministry of Science and Technology of the People’s Republic of China, National Natural Science Foundation of China, and Beijing Nova Program. Declaration of Interest: None to declare. Ethical Approval: This study was approved by the Institutional Review Board of Beijing TianTan hospital which covers all the hospitals contributing data to this study as part of the Chinese Stroke Center Alliance

Pre-stroke dementia and in-hospital outcomes in the Chinese Stroke Center Alliance

Little is known about the prevalence of pre-stroke dementia in China and whether this group is at higher risk of adverse in-hospital outcomes. We aimed to understand this association using data from the Chinese Stroke Center Alliance. Multivariable logistic regressions were conducted to assess the association between pre-stroke dementia status and ambulation at day 2, in-hospital mortality, and in-hospital complications. Covariates included age, sex, medical history, history of smoking, history of alcohol use, medication history (antiplatelet drugs, lipid-lowering drugs), stroke severity (measured by the National Institute of Health Stroke Scale), whether IV tPA was administered within 4.5 hours, and whether the patient received deep vein thrombosis prophylaxis as needed. Odds ratios and 95% confidence intervals were presented for the adjusted models. In the final analytic sample of 559,070 ischemic stroke patients with no prior stroke history enrolled across 1476 hospitals, 1511 (0.3%) had pre-stroke dementia, and they were older and more likely to be female. Patients with pre-stroke dementia had lower odds of ambulating at day 2, higher odds of having any complications and higher odds of in-hospital mortality compared to those without pre-stroke dementia, despite little difference in treatment received. Our findings may be explained by communication barriers experienced by patients with pre-stroke dementia that limited their ability to advocate for their own care needs. Further research is needed to determine whether a different care pathway or additional attention from clinicians is necessary for patients with pre-stroke dementia.

China Stroke Statistics 2019: A Report From the National Center for Healthcare Quality Management in Neurological Diseases, China National Clinical Research Center for Neurological Diseases, the Chinese Stroke Association, National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention and Institute for Global Neuroscience and Stroke Collaborations

China faces the greatest challenge from stroke in the world. The death rate for cerebrovascular diseases in China was 149.49 per 100 000, accounting for 1.57 million deaths in 2018....

Impact of Infection on the Risk of Recurrent Stroke Among Patients With Acute Ischemic Stroke.

Infection occurs commonly in patients with acute ischemic stroke. We aimed to investigate the association of infection with short- and long-term risk of recurrent stroke in patients with ischemic stroke. Data were derived from ischemic stroke patients in 2 stroke registries: the CSCA (Chinese Stroke Center Alliance) program recorded medical data during hospitalization, and the CNSR-III (Third China National Stroke Registry) recorded the medical data during hospitalization and finished 1-year follow-up. Associations of infection (pneumonia or urinary tract infection) during hospitalization with recurrent stroke in short (during hospitalization) and long term (since 30 days to 1 year after stroke onset) were analyzed. Short-term outcomes were analyzed with logistic models and long-term outcomes with Cox models. In the CSCA (n=789 596), the incidence of infection during hospitalization reached 9.6%. Patients with infection had a higher risk of stroke recurrence during hospitalization compared with patients without infection (10.4% versus 5.2%; adjusted odds ratio, 1.70 [95% CI, 1.65-1.75]; P<0.0001). In the CNSR-III (n=13 549), the incidence of infection during hospitalization was 6.5%. Infection during hospitalization was significantly associated with short-term risk of recurrent stroke (7.4% versus 3.9%; adjusted odds ratio, 1.40 [95% CI, 1.05-1.86]; P=0.02) but not with long-term risk of recurrent stroke (7.2% versus 5.2%; adjusted hazard ratio, 1.16 [95% CI, 0.88-1.52]; P=0.30). Infection was an independent risk factor for high risk of early stroke recurrence during hospitalization, but we have not found its sustained effect on long-term recurrent risk in patients with acute ischemic stroke.

Renal Dysfunction and In-Hospital Outcomes in Patients With Acute Ischemic Stroke After Intravenous Thrombolytic Therapy.

BackgroundThe impact of estimated glomerular filtration rate (eGFR) on clinical short‐term outcomes after stroke thrombolysis with tissue plasminogen activator remains controversial.Methods and ResultsWe analyzed 18 320 ischemic stroke patients who received intravenous tissue plasminogen activator at participating hospitals in the Chinese Stroke Center Alliance between June 2015 and November 2017. Multivariate logistic regression models were used to evaluate associations between eGFR (<45, 45–59, 60–89, and ≥90 mL/min per 1.73 m2) and in‐hospital mortality and symptomatic intracerebral hemorrhage, adjusting for patient and hospital characteristics and the hospital clustering effect. Of the 18 320 patients receiving tissue plasminogen activator, 601 (3.3%) had an eGFR <45, 625 (3.4%) had an eGFR 45 to 59, 3679 (20.1%) had an eGFR 60 to 89, and 13 415 (73.2%) had an eGFR ≥90. As compared with eGFR ≥90, eGFR values <45 (6.7% versus 0.9%, adjusted odds ratio, 3.59; 95% CI, 2.18–5.91), 45 to 59 (4.0% versus 0.9%, adjusted odds ratio, 2.00; 95% CI, 1.18–3.38), and 60 to 89 (2.5% versus 0.9%, adjusted odds ratio, 1.67; 95% CI, 1.20–2.34) were independently associated with increased odds of in‐hospital mortality. However, there was no statistically significant association between eGFR and symptomatic intracerebral hemorrhage.Conclusions eGFR was associated with an increased risk of in‐hospital mortality in acute ischemic stroke patients after treatment with tissue plasminogen activator. eGFR is an important predictor of poststroke short‐term death but not of symptomatic intracerebral hemorrhage.

Use of Emergency Medical Services and Timely Treatment Among Ischemic Stroke.

Background and Purpose- Emergency medical services (EMSs) are critical for early treatment of patients with ischemic stroke, yet data on EMS utilization and its association with timely treatment in China are still limited. Methods- We examined data from the Chinese Stroke Center Alliance for patients with ischemic stroke from June 2015 to June 2018. Absolute standardized difference was used for covariates' balance assessments. We used multivariable logistic models with the generalized estimating equations to account for intrahospital clustering in identifying demographic and clinical factors associated with EMS use as well as in evaluating the association of EMS use with timely treatment. Results- Of the 560 447 patients with ischemic stroke analyzed, only 69 841 (12.5%) were transported by EMS. Multivariable-adjusted results indicated that those with younger age, lower levels of education, less insurance coverage, lower income, lower stroke severity, hypertension, diabetes mellitus, and peripheral vascular disease were less likely to use EMS. However, a history of cardiovascular diseases was associated with increased EMS usage. Compared with self-transport, EMS transport was associated with significantly shorter onset-to-door time, door-to-needle time (if prenotification was sent), earlier arrival (adjusted odds ratio [95% CIs] were 2.07 [1.95-2.20] for onset-to-door time ≤2 hours, 2.32 [2.18-2.47] for onset-to-door time ≤3.5 hours), and more rapid treatment (2.96 [2.88-3.05] for IV-tPA [intravenous recombinant tissue-type plasminogen activator] in eligible patients, 1.70 [1.62-1.77] for treatment with IV-tPA by 3 hours if onset-to-door time ≤2 hours, and 1.76 [1.70-1.83] for treatment with IV-tPA by 4.5 hours if onset-to-door time ≤3.5 hours). Conclusions- Although EMS transportation is associated with substantial reductions in prehospital delay and improved likelihood of early arrival and timely treatment, rate of utilization is currently low among Chinese patients with ischemic stroke. Developing an efficient EMS system and promoting culture-adapted education efforts are necessary for improving EMS activation.

Abstract TP356: Renal Function and In-Hospital Outcomes in Patients With Acute Cerebrovascular Disease: Results From Chinese Stroke Center Alliance

Background and Purpose: To investigate the association of renal function with in-hospital death and recurrent stroke in patients with acute stroke. Methods: Data were from the Chinese Stroke Center Alliance (CSCA) with a sample of 511 036 patients. Baseline eGFR was calculated with the Chinese modification of CKD-EPI equation and categorized into 4 groups. Logistic regression models with generalized estimating equations were used to evaluate the risks for in-hospital death and recurrent stroke among eGFR categories with and without stratification for hypertension, diabetes mellitus (DM) and atrial fibrillation (AF). A cubic spline smoothing technique was used to interpolate the overall trend of risks through the range of eGFR. Results: Of 501 497 patients, 70.1% had an eGFR ≥90, 21.7% an eGFR 60 to 89, 4.1% an eGFR 45 to 59, 4.1% an eGFR&lt;45 mL/min/1.73 m 2 . In-hospital death occurred in 3.0% of patients with an eGFR of &lt;45, 1.5% an eGFR of 45 to 59, 0.9% an eGFR of 60 to 89, and 0.5% an eGFR ≥90. Recurrent stroke occurred in 7.6%, 7.2%, 6.5% and 5.9% respectively. Compared with eGFR ≥ 90, the adjusted odds ratios with 95% CI of eGFR &lt;45, 45-59 and 60-90 were 3.97 (3.42-4.61), 1.95 (1.70-2.45) and 1.37 (1.22-1.53) for in-hospital death and 1.02 (0.94-1.11), 0.98 (0.91-1.06) and 0.98 (0.93-1.03) for recurrent stroke. A significantly statistical interaction between DM and categories of eGFR for stroke recurrent was identified (interaction P =0.001). The other results were almost consistent in stratified analyses by hypertension, DM or AF. There was a J-shaped relationship between eGFR and in-hospital death. A linear relationship was observed between eGFR and recurrent stroke. Conclusions: Low eGFR was associated with increased risk of all-cause mortality but not with recurrent stroke in patient with acute stroke.

Abstract WP416: Preceding Therapeutic Anticoagulation in Patients With Atrial Fibrillation Reduces Both the Severity of Stroke and the Risk of In-Hospital Complications--Data From the Chinese Stroke Center Alliance (CSCA)

Objectives: To determine the association of preceding therapeutic anticoagulation with stroke severity and in-hospital complications. Method: All acute ischemic stroke patients with known history of AF, who were included into CSCA, were divided into five groups: not receiving any antithrombotic therapy, only antiplatelet therapy, receiving subtherapeutic warfarin (international normalized ratio [INR] &lt;2), receiving therapeutic warfarin (INR≥2) and receiving non-vitamin K antagonist oral anticoagulants (NOACs). Stroke severity was measured by the National Institutes of Health Stroke Scale (NIHSS, a score ≥16 indicating moderate or severe stroke), and in-hospital complications included pneumonia, deep vein thrombosis, pulmonary embolism, seizures, hydrocephalus, urinary tract infections, hemorrhoids, depression, myocardial infarction and gastrointestinal bleeding. Results: Of 25 475 patients (mean [SD] age, 73.7 [10.6] years; 51.1% male), none were receiving NOACs, 438 (1.7%) were receiving therapeutic warfarin, 2 520 (9.9%) were receiving subtherapeutic warfarin, 5 847 (23.0%) were receiving antiplatelet therapy only, and 16 670 (65.4%) were not receiving any antithrombotic treatment before onset of stroke. Among 22 113 high-risk patients (prestroke CHA2DS2-VASc score ≥2), 19 546 (88.4%) were neither receiving warfarin nor NOACs before stroke. After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeutic warfarin, untheraputic warfarin, or antiplatelet therapy only was associated with lower odds of moderate or severe stroke (adjusted odds ratio [95% CI], 0.71 [0.53-0.93], 0.88 [0.78-0.99], and 0.87 [0.80-0.96], respectively) and in-hospital complications (adjusted odds ratio [95% CI], 0.79 [0.62-1.00], 0.88 [0.79-0.98], and 0.99 [0.91-1.07], respectively). Conclusions: Among Chinese patients with acute ischemic stroke and known history of atrial fibrillation, therapeutic anticoagulation was associated not only with lower odds of moderate or severe stroke but also with lower odds of in-hospital complications.

Abstract WP393: Usage of Emergency Medical Services Among Ischemic Stroke Patients: Data From China Stroke Center Alliance

Background and Purpose: Emergency medical services (EMSs) is critical for the early treatment of ischemic stroke patients, yet data regarding EMSs utilization and its association with timely treatment are still limited in China. Methods: We examined the data from Chinese Stroke Center Alliance (CSCA) recording consecutive ischemic stroke patients from 2015 June to 2017 November. The absolute standardized difference was used for covariates balance assessments. We used multivariable logistic models to identify factors associated with EMSs usage and to evaluate the effect of EMSs on timely treatment. Results: Of the 326,534 analyzed ischemic patients, only 42,293 (13.0%) were transported by EMSs. Multivariable-adjusted results indicated that younger age, less education, non-urban employ medial insurance, lower income level, less stroke severity, smoking, history of stroke/transient ischemic attack, carotid stenosis, hypertension, diabetes and peripheral vascular disease were associated with decreased risk of EMSs usage. However, coronary heart disease or myocardial infarction, atrial fibrillation and heart failure were associated with increased risk of EMSs usage. Compared to self-transportation, EMS-transported patients were associated with significantly shorter onset-to-door time (Median (IQR): 210 (105-586) vs. 1020 (290-2250) minutes, P&lt;0.0001), higher chance of arrival at hospitals within 2 hours (32.0% vs 9.4%, OR=3.77, 95% CI: 3.53-4.02) or within 3.5 hours (50.1% vs 19.0%, OR=3.60, 95% CI, 3.35-3.86) after symptom onset, and treated with IV tPA (13.8% vs 3.6%, OR=3.06, 95% CI:2.75-3.41). Conclusions: EMSs utilization is far from optimal among Chinse ischemic stroke patients. Nevertheless, use of EMSs transportation is associated with substantial reductions in prehospital delay and improved chance of timely treatment. Therefore, community education efforts are needed to improve EMSs activation.

Abstract TP354: Usage of New Oral Anticoagulants Among Acute Ischemic Stroke Patients with Atrial Fibrillation in China: Findings from Chinese Stroke Center Alliance

Background and Purpose: Previous studies have reported the underuse of warfarin for ischemic stroke patients with atrial fibrillation (AF) in China. New oral anticoagulants (NOACs) have become an efficacious alternative to warfarin and been recommended by guidelines. We sought to explore the usage of NOAs and affecting factors in China. Methods: From June 2015 to November 2017, 511 036 patients with acute stroke/TIA were admitted to 1 624 hospitals voluntarily participating in the China Stroke Center Alliance (CSCA), an ongoing, national, hospital-based, multicenter, stroke care quality registry and improvement program. Multivariable logistic regression models using the generalized estimating equation method were used to identify patient/hospital factors independently associated with NOACs use during hospitalization. Results: Among 28 456 ischemic stroke patients with AF, only 798 (2.8%) received NOACs, 8 635 (30.3%) received traditional anticoagulants therapy, 18821 (66.1%) received antiplatelet drugs only. Among patients receiving traditional anticoagulants or NOACs, younger age, lower education level, lower income, rural basic medical insurance schemes, more severity, secondary hospital, Central or West China were associated with lower odds of receiving NOACs (Table 1). Conclusions: Ischemic stroke patients with AF are under treated with anticoagulant, especially with the usage of NOACs. Further efforts are needed to increase the prescription of NOACs and other anticoagulants.

Stroke care quality in China: Substantial improvement, and a huge challenge and opportunity.

Stroke is The first two authors contributed equally. the leading cause of death and adult disability in China. Although evidence-based clinical interventions have been identified to improve care and outcomes in stroke, significant gaps still exist between guideline recommendations and clinical practice in China. Regional and national stroke registries have been used to assess the benchmark of stroke care quality, provide feedback on compliance with evidence-based performance measures to health care providers, and continuously improve stroke care quality without increasing additional medical costs in the past several decades worldwide. In China, stroke care has become a national priority. A series of stroke care quality assessment and improvement actions was initiated by the Ministry of Health to increase the detection of high-risk populations with stroke, rate of adherence to evidence-based process performance measures of stroke care, and stroke care organization development, aiming to decrease the burden of stroke. China National Stroke Registries have been started in 2007, and they are conducted every 3 to 5 years. A carotid disease screen and intervention project for communities was initiated in 2009. The Chinese Stroke Association, founded in 2015, launched the Chinese Stroke Center Alliance to increase the stroke center design in the near future. In this article, we described these stroke care actions and progression, summarized the benchmark and improvement of stroke care quality, and outlined the future plans in China.