Days Of Ischemic Stroke Research Articles

Preventable Readmissions Within 30 Days of Ischemic Stroke Among Medicare Beneficiaries

The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown. Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged≥65 years discharged alive with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification 433, 434, 436) between December 2005 and November 2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated. Random-effects logistic regression was also used to determine patient-level factors associated with preventable readmissions. Among 307 887 ischemic stroke discharges, 44 379 (14.4%) were readmitted within 30 days; 5322 (1.7% of all discharges) were the result of a preventable cause (eg, pneumonia), and 39 057 (12.7%) were for other reasons (eg, cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions. On the basis of Agency for Healthcare Research and Quality Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the Agency for Healthcare Research and Quality measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and costs should target high-risk patients.

Recent Trends in Inpatient Mortality and Resource Utilization for Patients with Stroke in the United States: 2005-2009

The aim of the study is to evaluate recent trends in mortality, length of stay, costs, and charges for patients admitted to the US hospitals with the principal diagnosis of stroke. This was a retrospective temporal trends study using data from the Nationwide Inpatient Sample from 2005 to 2009. During the study period, there were 2.7 million hospital admissions with the diagnosis of stroke in the United States (470,000 intracerebral hemorrhage, 130,000 subarachnoid hemorrhage, and 2.1 million ischemic strokes). In-hospital mortality decreased from 10.2% in 2005 to 9.0% in 2009 (26.0%-23.0%, 23.4%-23.1%, and 6.0%-5.1% for the stroke subtypes, respectively), the average length of stay decreased from 6.3 days to 5.9 days (5.6-5.2 days for ischemic stroke, remained the same for hemorrhagic stroke), and the average number of 1.3 ± 0.1 procedures per admission remained the same. The proportion of patients with major or extreme severity of illness increased from 39.2% to 47.0% (P < .0001). After adjustment for inflation, the average total charge per admission increased from $36,215 to $46,518 (P < .0001), whereas the average cost of treatment remained the same. Higher treatment cost is associated with lower in-hospital mortality after adjustment for demographic, hospital-related, and clinical confounders (odds ratio = .968 [.965-.970] per each extra $1000). Between 2005 and 2009, in-hospital mortality for patients hospitalized with stroke improved despite increasing severity of illness. At the same time, the average charge for hospitalization increased by 28% despite unchanged cost of treatment and shorter length of stay.

Correlation between serum neuron specific enolase and functional neurological outcome in patients of acute ischemic stroke

Context:The use of biomarkers to predict stroke prognosis is gaining particular attention nowadays. Neuron specific enolase (NSE), which is a dimeric isoenzyme of the glycolytic enzyme enolase and is found mainly in the neurons is one such biomarker.Aims:This study was carried out on patients of acute ischemic stroke with the aims to determine the correlation between NSE levels on the day of admission with infarct volume, stroke severity, and functional neurological outcome on day 30.Materials and Methods:Seventy five patients of acute ischemic stroke admitted in the Department of Medicine were included in the study. Levels of NSE were determined on day 1 using the human NSE ELISA kit (Alpha Diagnostic International Texas 78244, USA). Volume of infarct was measured by computed tomography (CT) scan using the preinstalled software Syngo (version A40A) of Siemen's medical solutions (Forchheim, Germany). Stroke severity at admission was assessed using Glasgow coma scale (GCS) and functional neurological outcome was assessed using modified Rankin scale (mRS) on day 30.Statistical Analysis Used:Statistical analysis was performed using the SPSS software for windows version 15.0 (SPSS).Results:A positive correlation was found between concentration of NSE on day 1 and infarct volume determined by CT scan (r = 0.955, P < 0.001). A strong negative correlation was found between GCS at presentation and concentration of NSE on day 1 (r = −0.806, P < 0.001). There was a positive correlation between NSE levels at day 1 and functional neurological outcome assessed by mRS at day 30 (r = 0.744, P < 0.001).Conclusions:Serum levels of NSE in first few days of ischemic stroke can serve as a useful marker to predict stroke severity and early functional outcome. However, larger studies with serial estimation of NSE are needed to establish these observations more firmly.

The PREP algorithm predicts potential for upper limb recovery after stroke

Stroke is a leading cause of adult disability and the recovery of motor function is important for independence in activities of daily living. Predicting motor recovery after stroke in individual patients is difficult. Accurate prognosis would enable realistic rehabilitation goal-setting and more efficient allocation of resources. The aim of this study was to test and refine an algorithm for predicting the potential for recovery of upper limb function after stroke. Forty participants were prospectively enrolled within 3 days of ischaemic stroke. First, shoulder abduction and finger extension strength were graded 72 h after stroke onset to compute a shoulder abduction and finger extension score. Secondly, transcranial magnetic stimulation was used to assess the functional integrity of descending motor pathways to the affected upper limb. Third, diffusion-weighted magnetic resonance imaging was used to assess the structural integrity of the posterior limbs of the internal capsules. Finally, these measures were combined in the PREP algorithm for predicting an individual's potential for upper limb recovery at 12 weeks, measured with the Action Research Arm Test. A cluster analysis was used to independently group patients according to Action Research Arm Test score at 12 weeks, for comparison with predictions from the PREP algorithm. There was excellent correspondence between the cluster analysis of Action Research Arm Test score at 12 weeks and predictions made with the PREP algorithm. The algorithm had positive predictive power of 88%, negative predictive power of 83%, specificity of 88% and sensitivity of 73%. This study provides preliminary data in support of the PREP algorithm for the prognosis of upper limb recovery in individual patients. PREP may enable tailored planning of rehabilitation and more accurate stratification of patients in clinical trials.

A feasibility study comparing two metabolic monitors in hospitalised patients following an ischaemic stroke

Background: Data on the energy requirements of patients following acute ischaemic stroke are scarce. A recent draft report highlighted the lack of data on physical activity levels during and following acute illness (SACN, 2009). The aims of this study were to establish if two metabolic monitors (CCM Express™ and the Sensewear™ armband) were feasible for use in hospitalised stroke patients and to determine the relative contributions of resting energy expenditure (REE) and physical activity to total energy expenditure (TEE). Methods: Eleven medically stable patients (seven male; four female) were recruited within 7 days of ischaemic stroke. Exclusion criteria: unable to give informed consent, receiving renal replacement therapy, body mass index (BMI) ≥ 50 kg m−2, known nickel allergy or receiving end-of-life care. All subjects were fasted from midnight and REE was measured early in the morning using the CCM Express™ for a period of up to 1 h (including establishment of steady-state (i.e. <10% difference in minute to minute VO2 and VCO2 measurements over 5 min). Concurrently, TEE was measured using the Sensewear™ armband for a period of 24 h. Assessments of patient acceptability and tolerance of both metabolic monitors were conducted by direct observation, completion of a checklist and, where clinically appropriate, a brief patient questionnaire. REE was compared with predicted basal metabolic rate (BMR) (Henry, 2005) and physical activity was estimated using the Metabolic Equivalent Task (MET) method, where 1.0 MET is equivalent to the energy expended at rest. Results: Mean age was 69.8 years (range 42–84 years) and mean (SD) BMI was 25.4 (5.2) kg m−2. All subjects were able to tolerate measurement of REE using the CCM Express™, although the facemask caused some discomfort to one subject with facial abrasions. Mean (SD) REE was 1257 (357) kcal day−1 and, perhaps unexpectedly, was lower than predicted BMR [1503 (226) kcal day−1; t-test, P = 0.07]. It was, however, difficult to achieve steady-state in four patients; thus, these REE measurements were unreliable. All subjects were able to tolerate measurement of TEE using the Sensewear™ armband. Mean (SD) TEE was 1663 (303) kcal day−1. Physical activity on the ward was very low, with subjects expending very little more energy than would be expected at rest [METS = 1.01 (SD 0.15)]. Discussion: Both metabolic monitors were well tolerated by the subjects; however, the unreliable REE measurements in some patients made it impossible to determine the relative contribution of REE to TEE. The results obtained regarding TEE and the low activity level in this study were comparable to results reported in other metabolic studies of patients who have had a stroke (Weekes & Elia, 1992; Finestone et al., 2003; Leone & Pencharz, 2010). Conclusions: Both metabolic monitors were feasible for use in patients following ischaemic stroke; however, some measurements of REE using the CCM Express™ were unreliable because of difficulties in establishing steady-state and the reasons for this merit further investigation. In this group of patients, physical activity on the ward was very low following a stroke.

Positional therapy in ischemic stroke patients with obstructive sleep apnea

Background Obstructive sleep apnea (OSA) is common in stroke patients and is associated with poor functional outcome. The effects of positional therapy in ischemic stroke patients with OSA have not been investigated. We tested the hypothesis that ischemic stroke patients have less severe OSA during positional therapy that promotes nonsupine positioning. Methods We conducted a randomized, controlled, cross-over study. Sleep apnea screening studies were performed on two consecutive nights, using a portable respiratory monitoring system, on 18 subjects within the first 14 days of ischemic stroke. An apnea–hypopnea index (AHI) ⩾5 established the diagnosis of OSA. Subjects were randomized to positional therapy that included the use of a therapeutic pillow on either the first or second night. On the control night, subjects used the hospital pillow and were positioned ad lib. Treatment effect on AHI was estimated using a repeated measures model. Results All ischemic stroke subjects studied had OSA. The predominantly male group had a median age of 58 years, BMI of 29 kg/m 2, NIH Stroke Scale score of 3, and a median AHI on the nontherapeutic night of 39 (interquartile range: 21–54). Positional therapy reduced the amount of supine positioning by 36% (95% CI: 18–55% ( P < 0.001)). The AHI was reduced by 19.5% (95% CI: 4.9–31.9% ( P = 0.011)), when using positional therapy compared to sleeping ad lib. Conclusions Positional therapy to avoid supine positioning modestly reduces sleep apnea severity after ischemic stroke, and may therefore improve outcomes.

MRI of the pharynx in ischemic stroke patients with and without obstructive sleep apnea

Background Obstructive sleep apnea (OSA) is common after stroke and associated with poor stroke outcomes. Whether OSA after acute stroke is caused by anatomic, physiologic, or both etiologies has not been studied. We therefore used brain magnetic resonance imaging (MRI) scans to assess oropharyngeal anatomy in stroke patients with and without OSA. Methods Patients within 7 days of ischemic stroke underwent nocturnal polysomnography. Sagittal T1-weighted MRI performed for clinical purposes was used to measure retropalatal distance, soft palatal length, soft palatal thickness, retroglossal space, and tongue length. Nasopharyngeal area and high retropharyngeal area were measured from axial T2-weighted images, and lateral pharyngeal wall thickness from coronal T1-weighted images. Results Among 27 subjects, 18 (67%) had OSA (apnea/hypopnea index (AHI) ⩾ 5). Demographics, vascular risk factors, and stroke severity were similar in the two groups. Median retropalatal distance was shorter in subjects with OSA (Wilcoxon rank-sum test, p = 0.03). Shorter retropalatal distance was associated with higher AHI (linear regression, p = 0.04). None of the other morphological characteristics differed. Conclusions Anatomic difference between awake acute stroke patients with and without OSA shows that the sleep disorder cannot be attributed solely to sleep, sleeping position, or changes in neuromuscular control that are specific to the sleep state.

The Specific Features of Oxygen Transport in the Acute Period of Ischemic Stroke

Objective: to study the oxygen transport system in the acute period of ischemic stroke (IS). Subjects and methods. Central hemodynamics and the oxygen transport system were studied, intracranial pressure was measured, cerebral perfusion pressure was calculated and neurophysiological and X-ray studies were conducted in 36 patients in the first 7 days of IS. Results. In the first 5 study days, circulatory hypoxia developed due to evolving hypodynamic circulation. Later on, the situation was deteriorated by arterial hypoxemia due to acute respiratory distress syndrome and increased pulmonary shunting. Simultaneously on days 5 and 7, there were reductions in the oxygen consumption index and oxygen extraction coefficient, which was due to vasoconstriction, higher blood flow velocity, and lower oxygen extraction. Neurophysiological evidence was used to diagnose sub- and decompensation of stem structural functions. Conclusion. Vasoconstriction leads to the development of circulatory hypoxia. Thus, the early period of ischemic stroke is marked by the decreased oxygen delivery index due to the development of hypodynamic circulation. This is further attended by pulmonary complications and microcircula-tory disorders. On day 5 of the acute period, noncardiogenic pulmonary edema developed and pulmonary shunt increased, by worsening hypoxia. Impaired function of stem structures due to their damage, as evidenced by clinical, neurophysiologi-cal, radiological, and autoptic studies, is one of the causes of hemodynamic disorders, thereby impairing the oxygen transport system. Key words: acute cerebral circulatory disorder, oxygen transport system.

Stroke in young adults

Background Stroke among young adults is generally considered a rare event, although few studies have considered national data. Objective The objective of this paper was to profile stroke in young adults in the United States using a national dataset. Methods Data from the 2007 Nationwide Inpatient Sample were examined to estimate the number of patients, mean length of stay, mean costs, and discharge disposition of young adults (aged 18-44 y) with a diagnosis of stroke. Results Estimates indicate that 41,587 (or 4.9%) of individuals experiencing a stroke in 2007 were young adults: 32,438 had an ischemic stroke, 4662 had a subarachnoid hemorrhage, and 4487 had an intracerebral hemorrhage. The average length of stay was 4.7 days for ischemic stroke, 11.6 days for subarachnoid hemorrhage, and 11.2 days for intracerebral hemorrhage. Approximately 5% (2013) of young adults died of stroke. Most young adults were discharged routinely to home at an average cost associated with their hospital stay of $34,886 for ischemic stroke, $146,307 for subarachnoid hemorrhage, and $94,482 for intracerebral hemorrhage. Conclusions A substantial number of young adults experience stroke in the United States at costs that are higher than those for stroke patients overall.

Acute treatment costs of intracerebral hemorrhage and ischemic stroke in Argentina

Stroke is the third leading cause of death in Argentina, yet little information exists on the acute treatment provided for stroke or its costs. This study estimates the national costs of the acute treatment of first-ever intracerebral hemorrhage (ICH) and ischemic stroke (IS) in Argentina. Retrospective hospital-based inception study design using data on resource use and costs from high-volume stroke centers in Argentina, and published population-based incidence data. Treatment provided at two large urban hospitals were evaluated in all patients admitted with a first-ever stroke between 1 January 2004 and 31 August 2006, and costs were assigned using appropriate unit cost data for all resource use. Cost estimates in Argentinian pesos were converted to US dollars ($) using the 2005 purchasing power parity index. National costs of acute treatment for incident strokes were estimated by extrapolation of average costs estimates to national incidence data. Assumptions of the average cost of stroke treatment on a national scale were examined in sensitivity analysis. The acute care of 167 patients with stroke was thoroughly evaluated from hospital admission to hospital discharge. Mean length of hospital stay was 35.4 days for ICH and 13.0 days for IS. Ninety-one percent of the patients with ICH and 68% of the patients with IS were admitted to an ICU for a mean length of stay (LOS) of 12.9 +/- 20.3 and 3.6 +/- 5.9 days respectively. Mean total costs of initial hospitalization were $12,285 (SD +/-14,336) for ICH and $3888 (SD +/-4018) for IS. Costs differed significantly by Glasgow Coma Scale (GCS) score at admission, development of pneumonia and infections during hospitalization, and functional outcome at hospital discharge. Aggregate national healthcare expenditures for acute treatment of incident ICH were $194.2m (range 97.1-388.4) and $239.9m for IS (range 119.9-479.7). The direct hospital costs of incident ICH and IS in Argentina are substantial and primarily driven by stroke severity, in-hospital complications and clinical outcomes. With the expected increase in the incidence of stroke over the coming decades, these results emphasize the need for effective preventive and acute medical care.

Effect of antihypertensive agents on cerebral blood flow and flow velocity in acute ischaemic stroke: systematic review of controlled studies

High blood pressure is common in acute stroke and is associated independently with poor outcome. Lowering blood pressure might improve outcome, provided it does not reduce cerebral blood flow in the presence of dysfunctional cerebral autoregulation. We performed a systematic review of clinical controlled trials that administered antihypertensive agents within 7 days of ischaemic stroke and measured cerebral blood flow or cerebral blood flow velocity. From 74 identified publications, 11 trials met the criteria. A variety of antihypertensive agents were used: angiotensin-converting enzyme inhibitors (three trials), angiotensin-receptor antagonists (one), calcium antagonists (five), diuretics (one) and nitrates (two). The trials' median quality score was 2.5/5, and the studies used single photon emission computed tomography (five trials), xenon-computed tomography (three) and positron emission tomography (one) for determining cerebral blood flow, and transcranial Doppler (six) for measuring flow velocity. Analysis of randomized controlled trials revealed no alteration in cerebral blood flow for any antihypertensive agent. Nonrandomized trials that assessed blood flow before and after administration of the agents showed an increase in blood flow for calcium channel blockers (standardized mean difference 0.43, 95% confidence interval 0.01-0.85). There are few quality studies assessing the effect of antihypertensive agents on cerebral blood flow and flow velocity, and variability in reporting make meta-analysis difficult. However, there is little existing evidence that antihypertensive agents reduce cerebral blood flow in spite of their effects on lowering blood pressure.

Ischemic Stroke and Intracerebral Hemorrhage: The Latest Evidence on Mortality, Readmissions and Hospital Costs from Scotland

Background and Purpose: Stroke is the third leading cause of death in the UK, yet little information exists on current treatment patterns, outcomes and costs. This study assessed survival, readmissions and total hospital costs over 12 months in patients with first-ever intracerebral hemorrhage (ICH) or ischemic stroke (IS) in Scotland. Methods: Hospital-based retrospective inception cohort design using data from the Hospital Record Linkage System in the National Health Service in Scotland. Survival, readmissions and total hospital costs were evaluated in all patients admitted to hospital for ICH or IS from April 1, 2004, to March 31, 2005. Results: A total of 1,016 patients with ICH and 4,295 with IS were identified. The average age was 67.6 years (SD 14.5) for ICH and 70.4 years (SD 12.7) for IS at stroke onset. In-hospital mortality was 45.2% (95% confidence interval, CI, 41.0–49.3) for ICH and 15.6% (95% CI, 14.4–16.7) for IS, while 52.5% (95% CI, 48.0–56.9) and 27.2% (95% CI, 25.7–28.8), respectively, were dead at 1 year after stroke onset. The cumulative 1-year risk of rehospitalization for stroke and severe cardiac events was 15.0 and 1.0% in the ICH cohort, respectively, and 10.8 and 1.5% in the IS cohort. The average length of initial hospital stay was 38.4 days for ICH and 39.3 days for IS. The average total hospital costs over 12 months were GBP 13,960 (SD 21,487) for ICH and GBP 14,051 (SD 17,850) for IS. Conclusion: Individuals experiencing an ICH continue to exhibit a much worse prognosis than IS, and both forms of stroke continue to imply significant hospital costs to the National Health Service in Scotland.

Effect of routine therapy and selective plasmapheresis on electrical properties of cryoglobulins during ischemic stroke

The charge properties of cryoglobulins were examined during the first 21 days of ischemic stroke (atherothrombotic and cardioembolic). Routine drug therapy produced no effect on the charge of cryoglobulins. Plasmapheresis significantly modified the electrokinetic parameters of cryoglobulins during atherothrombotic stroke and produced less pronounced effect on these proteins during cardioembolic stroke.

Hospital cost of ischemic stroke and intracerebral hemorrhage in Japanese stroke centers

Backgrounds: In Japan, the healthcare expenditure has increased to 8.0% of the gross domestic products in 2001. Stroke care is costly. Objective: To examine hospital costs and clinical outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) in Japanese stroke centers. Design: A prospective non-interventional multi-center study. Setting: Ten Japanese stroke centers. Study period: Fourteen months between October 2000 and December 2001. Patients: Patients were those who were consecutively hospitalized with acute IS or ICH within 72 h of onset, excluding subarachnoid hemorrhage. Stroke was defined as focal neurological deficits lasting more than 24 h and the relevant lesions were to be confirmed by brain CT and/or MRI. Methods: We examined demography, in-hospital cares, length of hospital stay, clinical outcomes at discharge, and direct hospital medical costs including physician's fees. The hospital medical cost data were collected from official hospital medical cost charts for reimbursement to the healthcare insurance systems. Results: There were a total of 1113 patients with a mean age of 70 years, of whom 913 (82%) patients had an IS and 200 (18%) patients had an ICH. The 317 patients (28%) experienced a recurrent stroke. Patients with ICH had the higher baseline stroke severity, resulting in longer hospitalization (39 days for IS and 46 days for ICH; P < 0.001), lower independence rate at discharge (55 and 40%; P < 0.001), higher mortality rate (5 and 10%; P = 0.03), and higher medical costs (US$ 8662 and US$ 10,260; P < 0.001) than those with IS. Patients with recurrent stroke had significantly older age, higher stroke severity, and lower independence rate at discharge than those with first-ever stroke. The length of stay, in-hospital mortality, and hospital medical costs were similar among first-ever and recurrent strokes. In subtype of IS, patients with cardioembolic stroke had the worst neurological deficits, poorest outcomes, and highest medical costs. The hospital costs had a greatest association with length of stay. Conclusions: Stroke care is costly in Japan. ICH is more likely to impose substantial physical and economic burden than IS. Because the cares of both first-ever and recurrent stroke were costly, primary and secondary prevention of stroke is important on the healthcare aspects.

Early Carotid Surgery in Acute Stroke: A Multicentre Randomised Pilot Study

Background: Standard practice has been to delay carotid endarterectomy (CEA) for 2 months following acute stroke to avoid a perceived risk of cerebral haemorrhage. We investigated whether early CEA reduces early recurrent stroke and improves outcome in partial anterior circulation infarction (PACI). Methods: Patients with PACI and a Barthel score of >18 before stroke underwent carotid duplex and CT imaging within 7 days of stroke. Forty consenting patients fit for surgery with greater than 70% ipsilateral carotid stenosis were randomised, 19 to ‘early’ (within 24 h) and 21 to ‘delayed’ surgery (at 8 weeks). Modified Rankin and Barthel scores were recorded at 1 week, 2 months, 6 and 12 months. Results: Rankin scores improved more rapidly following ‘early’ surgery to a score of 1 (0–4) at 2 and 6 months compared with 2.5 and 2 (1–4), respectively, for delayed surgery (p < 0.05). Barthel scores were also significantly improved following ‘early’ CEA at 7 days but both groups reached a median score of 20 by 2 months. Four ‘delayed’ and 3 ‘early’ patients suffered extension or recurrence of neurological deficits with 1 death in each group. Conclusions: Early CEA within 7 days of ischaemic stroke improved functional outcome with earlier hospital discharge. A large multicentre study is needed to exclude the possibility that ‘early’ CEA increases the risk of cerebral haemorrhage or death.

Resource Utilization and Costs of Stroke Unit Care in Germany

Objectives Stroke imposes a considerable economic burden on the individual and society. Recently, the concept of an integrated stroke unit has been established in several countries to improve the outcome of patients. This study evaluates the costs of acute care of the different cerebrovascular insults in a stroke unit. Methods The study population included 340 patients who were consecutively admitted to the Department of Neurology, Philipps University Marburg, with the diagnosis of stroke or transient ischemic attack (TIA) between January 1 and June 30, 2000. Clinical status and course were evaluated by using the Barthel index and the modified Rankin scale. Employing a “bottom-up” approach, we calculated the costs from the perspective of the hospital and the third-party payer using data from provider departments and other published sources. Results Inpatient costs were €3020 (US$3290) for TIA, €3480 (US$3790) for ischemic stroke (IS), and €5080 (US-$5540) for intracerebral hemorrhage (ICH) and differed significantly among these subgroups ( P < .05). Patient subgroups ranked in the same order for average length of stay at 9.4 days for TIA, 10.2 days for IS, and 11.9 days for ICH ( P > .05). Approximately 30% of the hospital costs are due to physician charges and care. Imaging amounted to 10% and lab investigations to 14% of total costs, independent of the diagnosis. Postacute treatment, including inpatient rehabilitation, cost €9880 per patient. Across all diagnostic groups, a mean clinical improvement was observed at time of discharge. Conclusions Care of patients with cerebrovascular events in a stroke unit causes a high demand of resources and has a considerable impact on health-care expenditure. Therefore, investigations comparing the stroke unit concept with other strategies in stroke care are necessary to evaluate the stroke unit concept for a rational use of available resources in patients with cerebrovascular events.

The Impact of the Day of the Week and Month of Admission on the Length of Hospital Stay in Stroke Patients

Background: Length of hospital stay (LOS) in many diseases is determined by patient-related sociodemographic and clinical factors but also by the management of treatment and care. We examined the influence of the day of the week (DW) and month of admission on LOS in stroke patients. Methods: We used data from a large regional stroke registry in the northwest of Germany for the years 2000 and 2001. The registry is based on a standardised data assessment in participating hospitals, including patient-related sociodemographic and clinical items, diagnostic and treatment procedures, stroke classification, as well as admission and discharge dates. Data management and analysis were done centrally. Results: A total of 11,942 patients from 42 hospital departments were included. Median LOS was 13 days for ischemic stroke and 8 days for TIA. Patients with ischaemic stroke admitted on Tuesdays or Wednesdays had the longest LOS. We observed a significantly shorter LOS in patients discharged towards the weekend, both for ischaemic stroke and TIA, independent of age, gender and symptom severity. Discharges were predominantly done on Fridays (25%), transferrals to rehabilitation centres most often on Thursdays (28%) in neurologic departments but on Tuesdays in departments of internal medicine. LOS according to the month of admission revealed a biphasic curve for both ischaemic stroke and TIA, with shortest LOS in July and December. Conclusions: Discharge patterns on weekends contribute to differences in LOS for the various DWs of admission. Changes in discharge organisation and improved co-operation with rehabilitation centres may shorten LOS. Differences in LOS between the months show considerable seasonal variability.

Serial analysis of the apparent diffusion coefficient time course in human stroke.

Acute cerebral ischemic injury can be rapidly detected on diffusion-weighted images. The apparent diffusion coefficient (ADC) depends on the stage of cytotoxic edema and water content in the infarcted parenchyma. The purpose of this study is to determine the time course of ADC during the first days of ischemic stroke. These data should make it possible to distinguish between multiple stroke and a single progressive infarction. Eight patients with clinically diagnosed acute cerebral ischemia were examined by diffusion-weighted MRI from 2 to 20 h after onset of symptoms. Daily control scans were performed for up to 10 days. ADC values were analyzed from 55 MRI studies. Furthermore, ADC was measured in the tissue which showed a hyperintense signal at the first examination and in the contralateral tissue. White and gray matter were analyzed separately. Data were expressed as the ratio ADC (rADC) of lesion to control region of interest. All patients showed a uniform reduction in rADC from the first hours of stroke and decreasing to the 3rd day. The rADC increased again from the 4th day up to the point of pseudo-normalization on day 9. The gray matter showed a slightly faster increase than the white matter. rADC shows significant changes in the first days after stroke, following a rather uniform time course. Together with T2-weighted MRI this makes it possible to differentiate between hyperacute, acute, and chronic stroke. Furthermore, the age of an ischemia can be determined and multiple strokes can be distinguished from a single progressive stroke.