Hospital-based Stroke Registers Research Articles

Completeness of case ascertainment in Swedish hospital-based stroke registers.

There is a worldwide development toward using data from hospital-based stroke registers to estimate epidemiological trends. However, incomplete case ascertainment may cause selection bias. We examined the completeness of case ascertainment and selection bias in two hospital-based Swedish stroke registers. First-ever stroke cases between March 2015 and February 2016 in the catchment area of Skåne University Hospital, Lund, Sweden, were included from multiple overlapping sources: two hospital-based stroke registers, Riksstroke-Lund and Lund Stroke Register (LSR); local outpatient and inpatient registers; primary care registers; and autopsy registers. The resulting population-based cohort was used as reference to assess completeness of case ascertainment and patient characteristics in Riksstroke-Lund and LSR. In total, 400 stroke patients were identified. Riksstroke-Lund detected 328 (82%) patients, whereas LSR detected 363 (91%). Patients undetected by hospital-based registers had higher 28-day case fatality than those detected (44% vs 9%; P=.001). Patients only detected in primary care (n=11) more often lived in healthcare facilities compared with those detected by hospital-based registers (57% vs 7%; P=.001). Patients not detected by Riksstroke-Lund, but detected by population-based sources, had less severe strokes (median NIHSS 3 vs 5; P=.013). Some first-ever stroke patients, such as those with high early case fatality and those with mild stroke, may go undetected with hospital-based screening used in clinical stroke registers. This can result in selection bias due to not identifying specific groups of patients including some with high early case fatality and those living in healthcare facilities.

Hospital-based stroke register studies and clinical features and outcomes of stroke patients in China and other Asian countries: A systematic review

Hospital-based stroke registration is an international research hotspot in recent years. This study aims to compare the current status and quality of hospital-based stroke registers in China and other Asian countries, and to analyze the clinical features and prognosis of stroke patients in these registries. Data were identified by electronic searches of electronic databases from January 2000 to November 2016. References were hand searched. We included the hospital-based stroke registry consecutively conducted in China and other Asian countries and analyzed these data prospectively. 80 articles from 32 stroke registries were included, sample size ranging from 1070 to 46108. The 32 registries covered five Asian countries, including China, Japan, South Korea, Thailand and Vietnam. Stroke classification and subtype (according to TOAST classification) are shown below. Thrombolysis rates was reported in only 5 registries in China, ranging from 0.9% to 19.3%,which were from 1.9% to 63.9% in 8 registries from other Asian countries. Case fatality rates were reported in 10 Chinese registries, 1-year death ranging from 1.58% to 26.1%,which were ranging from 3% to 26.3% in 10 registries from other Asian countries. In terms of thrombolysis, Chinese patients are less active, but there is not much difference in mortality in one year. However, due to the limitations of the research methods, data on the clinical characteristics of stroke patients is not reliable in making any conclusive decisions. This study calls for a set of quality criteria to assess stroke registration studies and to confirm their validity and feasibility.

Hospital-based Stroke Register Studies and Clinical Features and Outcomes of Stroke Patients in China and other Asian Countries: A Systematic Review (P4.3-044)

Hospital-based Stroke Register Studies and Clinical Features and Outcomes of Stroke Patients in China and other Asian Countries: A Systematic Review (P4.3-044)

Surgery for Supratentorial Spontaneous Intracerebral Haemorrhage: A Retrospective Analysis from a Hospital-based Stroke Register

Introduction: Intracerebral haemorrhage (ICH) constitutes about 5% to 20% of all strokes. Surgery for ICH has always been controversial with conflicting opinions. While multiple trials have doubted the positive effect of surgery in supratentorial ICH, it is now increasingly practiced across the world. The present study attempts to study outcome predictors following surgical evacuation for supratentorial ICH. Methodology: This is a retrospective analysis from a prospective ICH register on all patients who underwent surgical evacuation for supratentorial ICH between January 2015 and December 2017. Preoperative variables and postoperative complications were analyzed. The outcome was measured by the Modified Rankin Scale (mRS) at discharge and 3 months. Results: Our study group of 94 patients included 78 capsuloganglionic, 13 lobar, and 3 thalamic hematomas. The mean age of the study cohort was 52.72 ± 12.2 years with an overall male preponderance. Major comorbidities included hypertension in 55 (58.5%) and diabetes mellitus in 17 (18.1%). The median preoperative Glasgow Coma Scale (GCS) was 9 and the mean hematoma volume was 49.32 ± 19.01 ml. Standard craniotomy and clot evacuation were done in 61 patients, whereas 33 patients underwent decompressive craniectomy with hematoma evacuation and expansile duroplasty. Majority of the patients (60/94) underwent surgical evacuation within 6 to 24 hours. Residual bleed was seen in 25 patients (34.4%) and rebleed occurred in 9 patients. Major complications included ventilator-assisted pneumonia (35.1%), meningitis (18.1%), and septicaemia (12.8%). Our overall surgical mortality was 31/94 (32.9%) and the median GCS at discharge was 11.5. Median mRS was 5 and 4 at discharge and 90 days, respectively. Age, GCS < 8, and rebleed were independent predictors of mortality in surgically operated patients ( P < .05). Nondominant hemispheric clots and lobar hematoma carry better long-term outcomes ( P < .05). The type, timing of surgery, and sex did not have a significant influence on the outcome. Conclusion: Surgical evacuation of spontaneous intracerebral hemorrhage helps in significantly reducing mortality for younger patients with a preoperative GCS > 8 and clot volumes between 20 and 40 ml. Lobar hematoma carries better long-term outcomes and rebleeding affects outcomes adversely. More studies in future are required to redefine surgical indications.

Stroke in the Young: Access to Care and Outcome; A Western Versus Eastern European Perspective

To develop effective strategies to address the needs of young patients with stroke, it is important to recognize what components of stroke care they receive. The aims of this study were to describe the provision of stroke care and the factors associated with 3-month mortality and disability (Barthel Index 0-14) in patients younger than 55 years across Western and Eastern Europe. Data from hospital-based stroke registers in Western Europe (7 centers, 6 countries) and Eastern Europe (4 centers, 3 countries) were analyzed. Of 1735 patients admitted to hospital, 201 (11.5%) patients were younger than 55 years (Western European centers 51%, and Eastern European centers 49%). Stroke department care was higher in Western centers (67%) than in Eastern centers (24%) (P < .001). Doctor (P < .001), therapy (P = .01), and nursing (P < .001) time were higher in Western centers. At 3 months, case fatalities between Western and Eastern centers were 8% versus 23% (P = .003). Patients in Eastern European centers were more likely to have disability at 3 months (odds ratio = 24.3, confidence interval = 1.2-494, P = .04). Young patients with stroke in Western Europe are more likely to gain access to a number of components of stroke care compared with those in Eastern Europe. The future challenge is to ensure that recommendations are adopted to ensure all young patients receive evidence-based stroke care across Europe.

Winter Excess in Hospital Admissions, In-Patient Mortality and Length of Acute Hospital Stay in Stroke: A Hospital Database Study over Six Seasonal Years in Norfolk, UK

Background: Several studies have examined the incidence and mortality of stroke in relation to season. However, the evidence is conflicting partly due to variation in the populations (community vs. hospital-based), and in climatic conditions between studies. Moreover, they may not have been able to take into account the age, sex and stroke type of the study population. We hypothesized that the age, sex and type of stroke are major determinants of the presence or absence of winter excess in morbidity and mortality associated with stroke. Methods: We analyzed a hospital-based stroke register from Norfolk, UK to examine our prior hypothesis. Using Curwen’s method, we performed stratified sex-specific analyses by (1) seasonal year and (2) quartiles of patients’ age and stroke subtype and calculated the winter excess for the number of admissions, in-patient deaths and length of acute hospital stay. Results: There were 5,481 patients (men = 45%). Their ages ranged from 17 to 105 years (median = 78 years). There appeared to be winter excess in hospital admissions, deaths and length of acute hospital stay overall accounting for 3/100,000 extra admissions (winter excess index of 3.4% in men and 7.6% in women) and 1/100,000 deaths (winter excess index of 4.7 and 8.6% in women) due to stroke in winter compared to non-winter periods. Older patients with non-haemorrhagic stroke mainly contribute to this excess. If our findings are replicated throughout England and Wales, it is estimated that there are 1,700 excess admissions, 600 excess in-patient deaths and 24,500 extra acute hospital bed days each winter, related to stroke within the current population of approximately 60 million. Conclusions: Further research should be focused on the determinants of winter excess in morbidity and mortality associated with stroke. This may subsequently reduce the morbidity and mortality by providing effective preventive strategies in future.

Standard method for developing stroke registers in low-income and middle-income countries: experiences from a feasibility study of a stepwise approach to stroke surveillance (STEPS Stroke)

Stroke is a leading global cause of death, with an estimated 5.8 million fatal events in 2005, two-thirds of which happened in low-income and middle-income countries. In these regions, epidemiological methods to establish hospital-based stroke registers for clinical audit or studies to estimate incidence are scarce. Our aim was to ascertain whether stroke registers could be set up in geographically diverse populations in low-income and middle-income countries, using standardised data-collection manuals and methods, before recommending their wider use. WHO's stepwise approach to stroke surveillance (STEPS Stroke) offers an entry point for countries to register stroke patients in health-information systems. The methods proposed in this strategy were tested in a feasibility study, which focused on hospitalised stroke patients in nine different surveillance sites located in five low-income and middle-income countries. Data collection was for a median of 12 months. Observed differences between men and women were adjusted for age and surveillance site with logistic-regression analyses. A total of 5557 stroke patients were registered; 91 people whose age was missing or younger than 15 years were excluded from the analyses. Mean age was 64.2 years (SD 14.6), and 2484 (45%) participants were women. Ischaemic stroke accounted for about two-thirds of events. Half of all patients were hospitalised the same day. Stroke subtype was verified in 4913 (90%) participants by diagnostic techniques. Women had lower odds of verification of stroke subtype compared with men after adjustment for age and surveillance site (odds ratio 0.69 [95% CI 0.56-0.86]; p=0.0006). STEPS Stroke can be used in diverse populations to provide data in a standardised manner in countries with little or no previous records of stroke. Future studies should concentrate on expansion beyond hospital case series by adding information for stroke patients treated outside the hospital, linked to census data for the source population from which the cases come.

Measurement of quality of care. Comparison of voluntary versus obligatory data collection for the hospital based stroke register Hessen, Germany

Measurement of quality of care. Comparison of voluntary versus obligatory data collection for the hospital based stroke register Hessen, Germany

Variations in care and outcome in the first year after stroke: a Western and Central European perspective

Background: There are significant variations in the short term patterns of care and outcome after a first stroke in Europe. Objective: To estimate the variation in stroke care and outcome...

Neuropsychological characteristics of mild vascular cognitive impairment and dementia after stroke.

Post-stroke cognitive impairment is frequent, with characteristic impairments of attentional and executive performance. The study aims to determine whether the profile and severity of impairment in vascular Cognitive Impairment No Dementia (vascular CIND) is intermediate between that seen in stroke patients without significant cognitive impairment and patients with post-stroke dementia and thus to establish if the potential value of vascular CIND is a useful concept for predicting further cognitive decline and dementia in stroke patients. Stroke patients (n=381) > 75 were recruited from representative hospital-based stroke registers in Tyneside and Wearside, UK. Sixty six age matched controls were also recruited. A detailed battery of neuropsychological assessments was completed 3 months post stroke. Deficits of attention (z=5.7; p <0.0001) and executive function (z=5.9; p <0.0001) were seen even in stroke patients without vascular CIND, compared to controls. However, stroke patients with CIND were significantly more impaired again on tests of executive function (z=10.3; p <0.0001) compared to those not meeting CIND criteria; and also had greater impairments of memory (z=10.4; p <0.0001) and language expression (z=10.1; p <0.0001). A similar overall profile of deficits was evident in the CIND and the dementia group, but specific deficits were significantly more pronounced in those with dementia, particularly in orientation (z=7.2; p <0.0001) and memory (z=5.8; p <0.0001). The current study indicates that attentional and executive impairments are frequent in stroke patients, but deficits of memory, orientation and language are more indicative of CIND and dementia. Further longitudinal studies are required to clarify the relationship between specific lesions and the progression of specific cognitive deficits in post-stroke patients.

Editorial Comment—Stroke Incidence Studies One Step Closer to the Elusive Gold Standard?

Stroke should be studied in a population-wide context because a large proportion of the burden of care for stroke is borne by health services outside the hospital sector and by families of affected patients.1,2 Assessing the need for stroke-related prevention strategies and health services, and geographical and secular trends in stroke burden, is best achieved with standardized population-based registers. Analyses limited to hospital cases, incomplete mortality data, or cases with varying criteria and definitions may distort results because of nonstandardized measures and nonrepresentative study populations. However, identifying all new stroke events in a population is particularly challenging, so that such epidemiological studies are relatively rare compared with studies using mortality data, hospital-based stroke registers, or incidence studies in younger age groups only.2,3 Moreover, even among published population-based stroke incidence studies, there are differences in the methodologies used to ensure completeness of case ascertainment. Until recently, assessing completeness of case ascertainment in stroke incidence studies has been performed directly (eg, repeated cross-sectional surveys of the study population) and/or indirectly (eg, …

The Lehigh Valley Stroke Program: Establishing a Communitywide, Hospital-Based Stroke Register

A communitywide, hospital-based stroke register has been established in the Lehigh Valley of Pennsylvania and New Jersey. The Lehigh Valley has about 600,000 inhabitants and is geographically somewhat isolated. Ninety-five percent of the people are white, and the population has an age-sex distribution like that of the United States as a whole. All patients falling into any of nine diagnostic categories of stroke or transient ischemic attack are registered on admission to a hospital, and medical, social, and demographic data are abstracted onto precoded data forms. A single neurologist assigns definitive diagnoses according to standardized criteria after reviewing all of the medical data. The stroke register provides a new and powerful tool for collecting population-based data on a large number of cases in a short-time. After adjusting for demographic differences, epidemiologic studies can be carried out that may be generalizable to the entire United States. Several organizational aspects of the register and its operation are described in this report, and examples of the types of information and statistics readily calculable from the data in the register are given. The completeness of the stroke ascertainment and the large population registered also offer an excellent opportunity for any interested researcher to investigate the relationships between medical, social, and demographic conditions on the one hand and stroke risk on the other; to study the efficacy of prevention and treatment programs; and to determine health care provision requirements in a well-defined population.