Higher Stroke Mortality Research Articles

Abstract 20: Patterns of Stroke Center Certification and the Impact on Stroke Mortality in Counties of New York State

Introduction: To establish a statewide stroke system in March 2019, New York State (NYS) created the Stroke Designation Program. Stroke centers (SCs) must be certified by a state-approved certifying organization (CO), which is tasked with initial designation and ongoing re-certification. Previous research has found an association at the national level between socioeconomic status and access to higher levels of acute stroke care. Objective: This study characterizes the relationship between socioeconomic status of NYS populations and stroke care level access by comparing median household income and wealth in counties with and without certified SCs. Methods: Population and median household income from the U.S. Census (2010), stroke epidemiological data from the Center for Disease Control, and Area Deprivation Index (ADI) data (ranked within NYS) from the Neighborhood Atlas, a project that quantifies disadvantage by census tract, were collected and averaged for each county. Income has been used to assess local wealth and ADI to analyze community health risks. Certification data were mined from quality check databases for The Joint Commission and Det Norske Veritas, the most commonly used COs. Student’s t-tests compared income and ADI in counties with at least one certified SC to those without. Linear regression characterized the relationship between income and ADI with number of certified SCs, stroke incidence and stroke mortality. Results: All 62 counties in NYS were investigated to yield 40 certified SCs. Counties with at least one certified SC had a significantly higher income ($68,183.63 vs. $57,155.12; p=0.03) and lower ADI (5.90 vs. 7.37; p=0.004) compared to counties with no certified SC. Higher income (p<0.001) and lower ADI (p<0.001) were also associated with more certified SCs. Counties with fewer certified SCs had significantly higher stroke mortality (p<0.001) despite having similar stroke incidence. Conclusion: Socioeconomic heterogeneity in NYS counties is correlated to differential access to certified SCs and quality stroke care, as fewer centers are found in lower-income and disadvantaged communities. Although populations with less access experience stroke at similar rates, this study finds higher death rates in these counties.

Abstract P695: Rural-Urban Differences in Functional Outcomes After Acute Therapy for Stroke

Introduction: The Southeastern United States, known as the “the stroke belt,” has the highest stroke mortality rate in the country. One possible reason is the high proportion of its residents living in rural areas. Studies suggest stroke care is worse for patients living in rural areas, and they are less likely to receive acute stroke therapy (intravenous thrombolysis or endovascular therapy), leading to worse outcomes. We compared 90-day modified Rankin Score (mRS) between patients living in urban versus rural areas who received acute stroke therapy. Methods: We performed a retrospective analysis of a tertiary care academic hospital in the Southeastern US, the University of Alabama at Birmingham. Patients admitted with imaging-confirmed ischemic stroke and had acute stroke therapy between 2014 and 2018 were included for analysis. Individuals were classified as rural or urban dwelling based on US Department of Agriculture’s 2010 Rural-Urban Commuting Area Codes. Clinical and demographic characteristics were collected from the chart. Stepwise logistic regression models were performed with these variables to compare good (mRS 0-1) vs poor (mRS 2-6) functional outcomes. Results: There were 232 patients included in the study (185 urban, and 47 rural). There were no significant differences between groups in age (urban 64.5±15.1; rural 66.2±14.7), gender (urban: 56% male 44% female, rural: 51% male 49% female), or proportion of African-Americans (33% of urban group and 25% of rural group). Mean baseline NIH stroke scale was higher in rural patients than urban (17.0 vs 14.8 respectively, p-value=0.03.). In logistical regression models for good functional outcome (mRS 0-1) at 90-days, analysis of factors including rural/urban status, gender, age, insurance, transfer, and acute stroke therapy, revealed only older age as a significant factor (OR 0.97, 95% CI 0.95-0.99). Conclusions: Our study demonstrated no significant differences in functional outcome between patients from urban and rural locations after receiving acute therapy for treating ischemic stroke. Importantly, only older age predicted poor functional outcome at 90 days. Our study demonstrates that patients from rural areas can recover similarly to those from urban areas.

Retinal Vasculature Fractal and Stroke Mortality.

Fractal analysis is a method of quantifying the branching complexity and density of the retinal vessels. We hypothesized that reduced fractal dimension, signifying a sparser vascular network, is associated with long-term stroke mortality. We examined the relationship of fractal dimension and stroke mortality in a prospective, population-based cohort of 3143 participants aged 49 years or older. Fractal dimension was measured from digitized fundus photographs using a computer-automated method. Stroke mortality was documented from Australian National Death Index records. We defined reduced fractal dimension as values in the lowest quartile. Over 12 years, there were 132 (4.2%) stroke-related deaths. Stroke-related mortality was higher in participants with reduced fractal dimension (lowest quartile) compared with the highest quartile (7.7% versus 1.3%, P<0.01). After controlling for age, gender, smoking, blood pressure, history of stroke, and other factors, participants with reduced fractal dimension had higher stroke mortality (hazard ratio, 2.42 [95% CI, 1.15-5.07], lowest versus highest quartile). When modeled as a continuous variable, reduced fractal dimension was associated with increased stroke mortality (multivariable-adjusted hazard ratio, 1.26 [95% CI, 1.06-1.51], per SD decrease). Reduced retinal vascular fractal dimension is independently associated with 12-year stroke mortality. Reduced fractal dimension may indicate cerebral tissue hypoxia and increased risk of stroke.

Risk factors, clinical outcomes and predictors of stroke mortality in Sierra Leoneans: A retrospective hospital cohort study

BackgroundStroke data from Sierra Leone is limited, despite the increase in global burden of the disease. The aim of this study was to assess the risk factors, clinical outcomes and predictors of stroke mortality at a tertiary hospital in Freetown, Sierra Leone. MethodsThis retrospective cohort study was conducted on stroke patients admitted at the Connaught Teaching Hospital between 1st January to December 31, 2018. Clinical data related to stroke, with variables including patients’ demographics, stroke subtype, vascular risk factors, modified Rankin Scale (mRS), and outcomes were documented. In-hospital mortality, associated risk factors and predictors of stroke were determined. The study was approved by the Sierra Leone Ethics and Scientific Review Committee. It was registered under Research Registry https://www.researchregistry.com/browse-the-registry#home/with the unique identifying number researchregistry6009. ResultWe studied 178 (95 male and 83 female) patients. The mean age was 59.8 ± 14.0 years, median was 58.1years (ranging: 29–88 years). The commonest risk factors were hypertension (84.3%), tobacco smoking (35.9%) and alcohol (31.4%). Ischemic stroke confirmed by CT scan was 76.3%. In-hospital mortality was 34.8% and at discharge, mean modified Rankin Score (mRS) was 3.89 ± 1.62. The independent predictors for stroke mortality were: hypertension [AOR = 2.2; C.I 95%: (1.32–3.80), p = 0.001], previous stroke [AOR = 2.31; C.I 95%: (1.43–5.74), p = 0.001], GCS < 8 [AOR = 6.06; C.I 95%: (3.17–12.79), p < 0.001], clinical diagnosis in the absence of imaging [AOR = 3.11; C.I 95%: (2.1–9.87), p = 0.001], hemorrhagic stroke [AOR = 2.96; C.I 95%: (1.96–9.54), p < 0.001], and aspiration pneumonia [(AOR = 3.03; C.I 95%:(1.44–6.36), p = 0.001]. Women had poorer outcome than men. ConclusionThis study highlights a high stroke mortality in a resource limited hospital, with some stroke patients having difficulties in accessing Computer Tomogram (CT) scan services. It illustrates the need to establish a stroke care setting to improve the quality of stroke care.

Recognition of stroke-related knowledge among community residents and the improvement after intensive health education: a cross-sectional study

BackgroundThe high morbidity, mortality, and disability rates of stroke constitute a heavy burden to the society. The level of understanding about stroke warning symptoms and first aid systems among community residents was generally low. The aim of our work is to investigate stroke-related knowledge in community residents of Jinjiang district of Chengdu and to raise public awareness about stroke through an intensive educational program.MethodsNine communities in Jinjiang district were sampled and a questionnaire about stroke-related knowledge was applied before and after stroke educational activities. We analyzed the impact of such activities in stroke recognition and management.ResultsWe collected 1685 valid questionnaires. The awareness about stroke risk before educational activities was 11.4%. The recognition of stroke warning signs among community residents was 29.8–59.5%. Among them, the recognition of major signs, such as limb weakness, language disorder, and imbalance was more than 50%. When faced with five stroke warning signs, the proportion of participants who chose to make an emergency call was 41.5%. Less than 10% of the participants chose to consult a doctor, take medicine, or wait. After strengthening publicity and educational activities regarding stroke, there was a significant improvement in the identification of stroke risk factors, warning signs, and stroke management. The percentage of participants who chose to make an emergency call increased from 53.2 to 82.7%.ConclusionsThe knowledge about stroke among community residents in Jinjiang District of Chengdu was low. Strengthening publicity and educational activities may raise awareness about stroke prioritizing call emergency after the onset of stroke signs.

Racial and Ethnic Disparities in Mortality in US Veterans Following an Incident Subarachnoid Hemorrhage

Background Blacks and Hispanics have been shown to have higher stroke mortality than Whites. However, few studies have investigated health disparities in post-stroke mortality for specific stroke types, such as subarachnoid hemorrhage (SAH). We analyzed risk of mortality by race/ethnicity after incident SAH in a national sample of stroke patients from the Veteran's Health Administration (VHA). Methods We included 742 patients (98% male, mean age 63±13 years) with a first occurrence of an inpatient SAH in a VHA hospital between 2002-2007. SAH was determined by ICD-9 code 430. We categorized patients as non-Hispanic White, non-Hispanic Black, or Hispanic. Veterans with a prior definite stroke type (including TIA) were excluded. We constructed a piecewise multivariate survival model for post event all-cause mortality, separated according to 1 year post admission follow-up intervals. We then looked at 30-day mortality for vascular and stroke specific deaths. Results The proportion of White, Black, and Hispanic patients was 66%, 23%, and 11% respectively. Total mortality at 30 days, 90 days, 1 year, and end of follow up was 22%, 27%, 33% and 54% respectively. Compared to Whites, Hispanics had higher mortality in the first 30 days post stroke (HR=1.67 95% CI=1.08-2.30), while Blacks and Whites experienced similar mortality (HR=1.02 95% CI=0.68, 1.54). Both Blacks and Hispanics had worse vascular (Black vs White HR=1.59 95% CI=0.95-2.66; Hispanic vs White HR=2.04 95% CI=1.13-3.66) and stroke-specific (Black vs White HR=1.47 95% CI=0.81-2.67; Hispanic vs White HR=2.12 95% CI=1.16-4.22) mortality (“case-fatality”) than Whites in the first 30 days. Conclusion Survivorship following subarachnoid hemorrhage varies in Veterans according to race and ethnicity. Further research into the severity of the stroke as well as risk factor control before and after stroke could help to improve our understanding of these differences.

Abstract TP187: Disparities in Secondary Stroke Prevention Among Filipinos in Hawaii

Introduction: In Hawaii, Filipinos have the highest stroke mortality for unclear reasons. The objective of this study is to elucidate racial-ethnic differences in the use of antithrombotics and statins upon discharge home from hospitalization among stroke survivors. Methods: The Get With the Guidelines-Stroke (GWTG-Stroke) data from January 2010 to December 2016 at the only Comprehensive Stroke Center in Hawaii was retrospectively reviewed. Subjects with non-ischemic stroke and with disposition other than home were excluded. Multivariable logistic regression models examined differences in appropriate medication use at discharge related to race/ethnicity compared with whites after adjusting for age, sex, insurance status, prior medication use and stroke risk factors. Results: Among a total of 2347 patients studied (621 (26%) whites (W), 302 (13%) Filipinos (FI), 838 (36%) other Asians (OA), 538 (23%) Native Hawaiians and other Pacific Islanders (NHOPI), and 48 (2%) other race (O)), FI were prescribed less antithrombotic agents at discharge [OR 0.56; 95% CI 0.380, 0.837] than W, while there were no racial-ethnic differences among OA, NHOPI and O compared to W. Age [OR 1.02; 95% CI 1.006, 1.03], prior antithrombotic use [OR 2.04, 95% CI 1.47, 2.82] and coronary artery disease/prior myocardial infarction [OR 2.04, 95% CI 1.23, 3.39] were also independent predictors of antithrombotic prescription upon discharge. For statin prescription upon discharge, there was no difference between FI and W. NHOPI race [OR 2.09; 95% CI 1.54, 2.83], age [OR 1.01, 95% CI 1.001, 1.02], female sex [OR 0.68; 95% CI 0.55, 0.84], prior anti-cholesterol medication use [OR 4.12, 95% CI 3.01 5.63], dyslipidemia [OR 1.91, 95% CI 1.47, 2.49] and carotid stenosis [OR 0.49, 95% CI 0.32, 0.74] were predictors of statin prescription upon discharge. Conclusions: Filipinos are less likely to be prescribed an antithrombotic for stroke prevention compared with whites after hospitalization for stroke.

Aging exacerbates neutrophil pathogenicity in ischemic stroke.

Ischemic stroke is major cause of disability and mortality worldwide, and aging is strong risk factor for poor post-stroke outcome. Neutrophils traffic rapidly to the brain following ischemic stroke, and recent evidence has suggested that aging may alter neutrophil function after tissue injury. In this study, we hypothesize that aging enhances the pro-inflammatory function of neutrophils, directly contributing to the poorer outcomes seen in aging patients. We utilized demographic data and biological specimens from ischemic stroke patients and an experimental mouse model to determine the correlation between age, neutrophil function and stroke outcomes. In ischemic stroke patients, age was associated with increased mortality and morbidity and higher levels of neutrophil-activating cytokines. In mice, aged animals had higher stroke mortality and morbidity, higher levels of neutrophil-activating cytokines and enhanced generation of neutrophil reactive oxygen species compared to young mice. Finally, depletion of neutrophils via a specific monoclonal antibody after ischemic stroke led to long-term benefits in functional outcome in aged male and female animals, with no benefit observed in young. These results demonstrate that aging is associated with augmented neutrophil pathogenicity in ischemic stroke, and that neutrophil-targeted therapies may confer greater benefit in aged subjects.

Stress hyperglycemia and electrolytes disturbance in patients with acute cerebrovascular stroke

BackgroundStroke is a medical emergency and considered the 2nd leading cause of mortality worldwide. High morbidity and mortality of stroke are due to some complications like cerebral edema, infection, and associated heart disease. Stroke may cause stress hyperglycemia and electrolyte disturbance that may be independent predictors for increased morbidity and mortality. Data on electrolyte disorder in neurological conditions especially acute stroke are somewhat scanty and not frequently interpreted.ObjectivesThe current study aimed to evaluate the effect of stress induced by acute stroke on the blood glucose and serum electrolytes and its relationship to the type, severity, and prognosis of stroke.Subjects and methodsA total of 100 patients admitted with acute stroke were included in the study. After informed consent, fasting blood sugar, glycosylated hemoglobin, serum sodium, and potassium levels were measured simultaneously. Stroke severity and outcome were assessed using the Glasgow Coma Scale.ResultsStress hyperglycemia was noted in 21 patients, out of which 62% presented with hemorrhagic stroke. Undiagnosed diabetes was found in 47% of cases. Also, 13 % of our patients had both stress hyperglycemia and electrolyte disturbance simultaneously. Mortality among hemorrhagic versus ischemic patients was 46% and 22%, respectively. The independent predictors of mortality were stress hyperglycemia, electrolytes disturbance, ischemic heart diseases, and type and admission severity of stroke.ConclusionStress hyperglycemia and electrolyte disturbance after acute stroke were found in 21% and 47% of patients respectively and may adversely affect outcome of stroke especially those with cerebral hemorrhage.

CD200-CD200R Interaction: An Important Regulator After Stroke.

The high mortality and morbidity rate of stroke is a chronic problem that plagues human society. The activation of microglia is one of the principal reasons why neuroinflammation induces cerebral dysfunction. Because of their vital functions in the regulation of neuroinflammation, microglia constitute an important target for stroke. Given that there is an innate self-preservation mechanism between neurons and microglia, the transmembrane glycoproteins on the surface of their membranes, namely CD200 and CD200R, have become a popular topic of research. Numerous studies have demonstrated that CD200-CD200R interaction, microglial activation, and poststroke neuroinflammatory damage are inextricably linked. In this review, we describe the above relationship from a new perspective. We specifically focus on neuroinflammation after stroke. The role of crosstalk of CD200-CD200R inhibitory immune ligand receptors in immune regulation will also be illustrated. Thus, we will see how poststroke injury can be influenced by the CD200-CD200R crosstalk. Finally, we will discuss the possibility of clinical application of the result of CD200-CD200R interaction to manage neuroinflammatory injury after stroke.

Age-Period-Cohort Analysis of Stroke Mortality Attributable to High Sodium Intake in China and Japan.

Background and Purpose- The aim of this study is to assess the long-term trends in stroke mortality attributable to high sodium intake in China and Japan during the period 1990 to 2016. Methods- The mortality data were obtained from the GBD study (Global Burden of Disease) 2016 and were analyzed using an age-period-cohort method. Results- The age-standardized mortality rates showed declining trends for high sodium intake-related stroke mortality. The overall net drifts per year were -3.1% for Chinese men and -5.0% for Chinese women; and -4.6% for Japanese men and -5.7% for Japanese women. The local drift values were below zero in all age groups for both sexes in both countries, and all local drift values of female participants were below their counterparts of male participants. The longitudinal age curves of high sodium intake-attributable stroke mortality increased rapidly for both sexes in China, whereas those of Japanese were slowly rising. The period and cohort rate ratios were found to have similar downward patterns for both sexes in both countries, with a quicker decline for women than for men (significantly with P<0.05 for all). Conclusions- The age-standardized mortality rates, the period effect and the cohort effect of stroke mortality attributable to high sodium intake in China and Japan have been declining in both sexes and all age groups from 1990 to 2016. Consequently, sodium-reduction strategies are of low cost and effective for the prevention of stroke. It is necessary to educate the nation with the correct knowledge on healthy diet and techniques to reduce salt consumption.

Force and aspiration on catheters utilized in the ADAPT technique in acute ischemic stroke: A bench top analysis

IntroductionGiven the high morbidity and mortality of stroke, there remains a demand for techniques that provide rapid and safe intervention while improving time to recanalization. The direct aspiration first pass technique (ADAPT) uses force and aspiration for clot removal without the aid of separators or retrievers. In this study, we compare the force and aspiration qualities of commercially available catheters. MethodsFour different catheters with varying inner diameters were set up in a bench top model to test catheter tip pressure and flow rate. Catheter tip pressure was measured by attaching the catheter to a vacuum pressure gauge and an aspiration pump. The flow rate was calculated by measuring the volume of room temperature water aspirated through each catheter over a given time. ResultsThe Microvention Sofia catheter generated the greatest tip force (21.32 g), and the Stryker AXS Catalyst 6 catheter generated the smallest tip force (15.88 g). The Penumbra ACE 068 catheter and Medtronic ARC catheter measured 20.87 g and 16.78 g respectively. The ACE 068 had highest rate of aspiration at 289 mL/min, and the Catalyst 6 catheter had the lowest rate at 214. The Microvention Sofia catheter had the second highest rate while the ARC had the third highest rate, measuring 285 mL/min and 256 mL/min, respectively. ConclusionsWhen using the ADAPT technique, knowledge of the tip force and catheter flow rate of newer catheters with larger distal inner diameters may guide selection of aspiration catheters. While this study demonstrates differences in tip force and flow rate of different commercially available catheters, clinical translation will require further testing and evaluation.

Abstract P405: Racial Disparities in Ischemic and Hemorrhagic Post-stroke Mortality in United States Veterans

Introduction: Blacks and Hispanics have been shown to have higher stroke mortality than non-Hispanic whites. However, this may be due to higher incidence of strokes in blacks and Hispanics. Fewer studies have investigated health disparities in post-stroke mortality stratified by stroke type. We studied risk of mortality by race/ethnicity after either incident acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH) in a national sample of patients from the Veteran’s Health Administration (VHA). Methods: We included patients with a first occurrence of an inpatient AIS or ICH in a VHA hospital between 2002-2007. We categorized patients as non-Hispanic white, non-Hispanic black, or Hispanic. Veterans with any prior stroke-related code were excluded. For each of AIS and ICH, we constructed a piecewise multivariate survival model for post event all-cause mortality. We separated follow-up intervals into &lt;30 day, 30-90 day, 90 day-1 year, and &gt;1 year post admission. Results: We identified 36,569 patients with an incident stroke in 2002-2007 (91% AIS, 9% ICH). The proportion of white, black, and Hispanic patients with AIS was 68%, 26%, and 6% respectively; and in ICH was 63%, 27%, and 10%. Compared to whites, blacks had better survival for AIS in the first 30 days, while Hispanics tended to have better survival in the 30-90 day and &gt;1 year intervals. With ICH, blacks had higher mortality in the first 30 days. (Table 1) Conclusion: Blacks experience better 30-day survival after AIS compared to whites, but worse 30-day survival after ICH. This may be driven by higher prevalence of hypertension in blacks leading to small vessel occlusion, which is associated with lower mortality, or poorer control of blood pressure in the setting of ICH, which is associated with higher mortality. Hispanic patients may have better long-term survival after stroke compared to whites, a ‘Hispanic paradox’ that has been shown in other studies. Stroke events should be stratified by ischemic and hemorrhagic type when evaluating for racial disparities in outcomes.

Social determinants and cardiovascular disease mortality in Panama, 2012\u20132016

BackgroundThe aims of this study were to determine the geographic and time variation of social determinants of health (SDH) and cardiovascular disease (CVD) mortality in Panama from 2012 to 2016, and to identify which of the SDH has the strongest correlation with a socioeconomic index (SEI).MethodsWe conducted an ecological study obtaining mortality from the National Mortality Register and socioeconomic variables derived from the National Household Survey (NHS). The International Classification of Diseases 10th revision codes I20–I25 and I60–I69 were used for ischemic heart disease (IHD) and stroke, respectively. Standardized age-adjusted mortality rates were calculated by direct method. Mortality rates and socioeconomic variables were evaluated together in a panel data model. A SEI was developed from factorial analysis by principal components with a polychoric correlation matrix. Provinces and regions were categorized in tertiles according to median value of the SEI score.ResultsThe NHS evaluated an average of 15,919 households per year. The mean of age throughout the study period was 41 years. The average monthly income increased, from US$ (SD) 331.94 (5.38) in 2012, to 406.24 (5.81) in 2016, whereas the social security health coverage remained in a range of 57–58%. The mean number of school years was twelve. Significant geographical and temporal variations in social determinants and mortality rates were observed throughout the country. Colon, categorized in the middle tertile according to the SEI, presented higher IHD mortality rates. Darién (in the lowest SEI tertile) Colón and Herrera had higher stroke mortality rates. The SEI categorized indigenous territories in the lowest tertile. Total years of education was the strongest correlated variable with the SEI, when we excluded the population living in indigenous territories. However, when this population was included, social security coverage had the strongest correlation with the SEI.ConclusionWe observed geographical and temporal disparities in SDH and CVD mortality rates. Further epidemiological studies are warranted in the provinces of Colón, Darien, Herrera and Los Santos to explore in-depth the higher CVD mortality rates observed in these provinces.

Abstract WP300: Characteristics and Prognosis of Transfer Patients to a Comprehensive Stroke Center in the Stroke Belt

Background: The stroke belt has a higher stroke mortality rate compared to other regions of the United States with Alabama recording about 3,000 deaths yearly. The University of Alabama at Birmingham (UAB) is the only comprehensive stroke center (CSC) in Alabama equipped to manage the most complex stroke patients. Objective: The purpose of this study was to determine the characteristics and prognosis of patients transferred to a comprehensive stroke center in the stroke belt. Methods: Data was abstracted from the electronic health records of patients admitted to the stroke service between 2016 and 2018. We assessed differences between transfer and non-transfer patients in terms of demographics, stroke severity, insurance, administration of alteplase (t-PA) and thrombectomy (IA). We also evaluated the relationship between the Alabama state stroke designation of the originating hospital including non-stroke centers (level 0), acute stroke ready hospitals, ASRH (level 3), primary stroke centers, PSC (level 2) and direct admissions to UAB (level 1) and characteristics and prognosis of patients. Results: 1107 patients were assessed for the study with 402(36%) being transfers. Race, NIHSS,TPA and IA use, discharge disposition were associated with the level of stroke center, as shown in the table. Level 2 centers transferred patients with more severe strokes, and a higher proportion of TPA and IA use. Non-transfer patients had the best outcome with Home as their primary discharge location compared to patients transferred from level 2 stroke centers. Conclusion: About 36% of our stroke discharge volume is a result of patients transferred to UAB from outside hospitals. We conclude that Level 2 stroke centers are appropriately transferring patients with more severe stroke to CSCs compared to transfers from non-stroke centers and acute stroke ready hospitals. Some of the patients transferred to a CSC from non-stroke centers and ASRHs could be managed at PSCs.

Stroke Deaths Rise, Life Expectancy Falls with Polluted Air

The connection between poor air quality and higher stroke mortality was strongest in southern states across a region known as the “stroke belt.”

Mortality and Predictors of Death Poststroke: Data from a Multicenter Prospective Cohort of Lebanese Stroke Patients

Background: Despite efforts to reduce stroke mortality rates, the disease remains a leading cause of death in Lebanon highlighting the importance of understanding risk factors and subsequent mortality. We examined mortality rates during the first year after acute stroke and the major short-term (1-month) and long-term (1-year) mortality predictors. Methods: Data were collected prospectively on hospitalized stroke patients from 8 hospitals in Beirut during a 1-year period. Patients were followed up for 1-year or until death. Mortality rates were assessed at 1-month and at 1-year poststroke and predictors of death were evaluated using Cox proportional hazard model. Results: A total of 191 stroke patients were included. Survival data were completed for over 97% of patients. Cumulative mortality rates were 14.1% at 1-month and 22% at 1-year. Predictors of short-term and long-term mortality in univariate analysis were low socioeconomic status, intensive care unit admission, decreased level of consciousness, stroke severity, and presence of complications. Marital status also predicted short-term mortality, while age greater than 64 years, atrial fibrillation, coronary heart disease, hypertension, Bamford and TOAST classifications and surgery need were also long-term mortality predictors. In multivariate analysis, stroke severity and presence of complications were predictors of death at 1-month and at 1-year. Low socioeconomic status, dependency in daily living activities, and the presence of comorbidities were additional predictors of 1-year mortality. Conclusions: Approximately 1 over 5 of patients did not survive 1-year after stroke. There is a need for public awareness campaigns to improve stroke knowledge, warning, and prevention which may reduce this high stroke mortality rate in Lebanon.

Impact of atrial fibrillation on in-hospital mortality of ischemic stroke patients and identification of promoting factors of atrial thrombi – Results from the German nationwide inpatient sample and a single-center retrospective cohort

Ischemic stroke is one of the leading causes of death and disability. Atrial fibrillation (AF) is a well-recognized risk factor for ischemic stroke.We aimed to investigate the impact of AF on in-hospital mortality of ischemic stroke patients and to identify parameters associated with intra-cardiac thrombogenic material.Patients were selected by screening the nationwide sample for ischemic stroke by ICD-Code (I63), stratified for AF. In this cohort, the association between in-hospital deaths and AF was investigated.In a second study, we performed a retrospective analysis of patients who underwent transesophageal echocardiography (TEE) for various reasons, assigned these to 2 groups based on the heart-rhythm (sinus-rhythm [SR] vs AF) and examined associations between clinical and echocardiographic parameters and intra-cardiac thrombogenic material.The Nationwide sample comprised 292,401 inpatients (48.5% females) with ischemic stroke. Incidence was 360 per 100,000 citizens, with an age-dependent increase. In-hospital mortality rate was 8.2%; AF patients had 1.85-fold higher mortality rate (12.1% vs 6.5%).In the retrospective study, 219 patients (median age 67 [59.1–77.3] years, 39.3% females) were included: 115 patients with AF (median age 71 [59.0–78.0] years, 41.7% females) and 104 patients (median age 68 [56.3–76.8] years, 36.5% females) with SR. Solid thrombus or spontaneous-echo-contrast) was detected in 16 TEEs. Atrial dimensions were significantly enlarged in AF patients. Age, blood-flow velocity in LAA, LAA diameters, atrial areas, AF, and CHA2DS2-VASc-score were associated with thrombogenic material.Incidence of ischemic stroke increased with age. AF was connected with higher stroke mortality. Presence of intra-cardiac thrombogenic material was associated with AF and most CHA2DS2-VASc-score factors. AF was associated with larger atrial dimensions and larger cavities favored thrombogenic material.

Document Analysis of Correlation between Climate and Stroke

Aim: The aim of the research is to determine characteristic of the correlation between climate and stroke through the analysis of relevant documents. Methods: We found 115 researches of temperature and season on stroke mortality/incidence and these were categorized according to location, meteorology, date span, data source and research sites’ latitudes. We divided the globe into 5 temperature zones based on latitude ranges: 0 - 10, 10 - 23.5, 23.5 - 40, 40 - 50, and >50 degrees, and allotted a zone to each country. Stroke mortality by five temperature zones was calculated per 100,000 people. Results: 70% of the researches came from latitudes greater than 40 degrees with 92% of researches located in Europe, USA, and Asia. The mortality range was 42 - 63 per 105 individuals within latitudes 0 - 40 degrees. In latitudes 40 - 66.5 degrees, a linear upward trend (y = 69.82x − 22.823, R2 = 0.99) was noticed. More than 75% of the research reports indicated a negative correlation between climate and stroke, and the proportion was almost 6 and 7 times greater than that of the fluctuation and non-correlation, respectively. The most frequently used research methods were regression analysis and time series analysis. Conclusion: All of the research results confirmed that lower temperature is associated with higher mortality and incidence of stroke, while higher latitude is correlated with higher stroke mortality, consistent with the temperature zones.

Presentation, Management, and Outcomes of Acute Stroke in Palestine.

BackgroundStroke is a leading cause of death and disability in the Middle East. Data on the uptake of evidence‐based practices are limited in the region. We aimed to examine patterns of stroke presentation, management, and outcomes at public Palestinian hospitals.Methods and ResultsComprehensive data from all patients with acute stroke admitted to 2 public hospitals in the West Bank of Palestine were prospectively collected. Acute stroke presentation patterns, in‐hospital evaluation and management, mortality, and stroke complications were evaluated. Data were available for 150 patients with acute stroke between September 2017 and May 2018. The mean (SD) age was 65 (14) years and 49% were women. Only 25% of patients utilized ambulance services for transportation to the hospital. All patient received head computed tomography scans, although few received other investigations such as magnetic resonance imaging (8%) or carotid Doppler (4%). Most patients with ischemic stroke received antiplatelet therapy (98%), although none received thrombolysis. Only 17% received physical therapy evaluation. In‐hospital mortality was 12%, 23% of patients had at least 1 poststroke complication, and the median modified Rankin Score at discharge was 4 (interquartile range, 2–5).ConclusionsWe identified high stroke mortality and discharge disability rates in Palestine. Key evidence‐based gaps were highlighted, suggesting opportunities for quality improvement.