Hospitalization For Acute Ischemic Stroke Research Articles

Anticoagulants versus Antiplatelet Treatment in the Medical Management of Carotid Floating Thrombus

Carotid free-floating thrombus (CFT) is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by flow on vascular imaging. Unfortunately, there is no clear consensus among experts on the ideal treatment for this pathology. Retrospective analysis of acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients diagnosed with CFT on computed tomography angiogram (CTA) between January 2015-March 2023. We aimed to compare two treatment regimens: anticoagulation (ACT) and antiplatelet (APT) in the treatment of CFT. APT regimens included the use of dual or single antiplatelets (DAPT or SAPT; aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin +/- ASA. Patients that underwent mechanical thrombectomy were excluded. During study time there were 8252 acute ischemic stroke hospitalizations, of which 135 (1.63 %) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.41years ± 12.82;p < 0.01). Other demographic variables were similar between ACT and APT groups. Complete CFT resolution on repeat vascular imaging was numerically higher at 30 days (58.8 vs 31.6 %, respectively; p = 0.1) and at latest follow-up (70.8 vs 50 %; p = 0.1) on ACT vs APT, respectively without reaching statistical significance. Similarly, there was numerically higher rates of any ICH with ACT compared to APT but it did not achieve statistical significance (27.6 % vs 13.5 %; p = 0.5). There were similar rates of PH1/2 hemorrhagic transformation, independence at discharge and similar hospital length of stay between ACT and APT groups. Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5 vs 55.2 %; p < 0.001). The rate of 30-day recurrent stroke was comparable among ACT and APT at 30 days (3.4 vs 0 %; p = 0.1, respectively). Subgroup analysis comparing exclusive ACT vs Dual APT lead to similar results. Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed medically with ACT vs APT. Larger prospective studies are needed.

Ischemic Stroke and Reduced Left Ventricular Ejection Fraction: A Multidisciplinary Approach to Optimize Brain and Cardiac Health.

Reduced left ventricular ejection fraction ≤40%, a known risk factor for adverse cardiac outcomes and recurrent acute ischemic stroke, may be detected during an acute ischemic stroke hospitalization. A multidisciplinary care paradigm informed by neurology and cardiology expertise may facilitate the timely implementation of an array of proven heart failure-specific therapies and procedures in a nuanced manner to optimize brain and cardiac health.

Trends and predictors of decompressive craniectomy in acute ischemic stroke, 2011-2020

IntroductionRates of decompressive craniectomy (DC) in acute ischemic stroke (AIS) have been reported to decline over time, attributed to an increase in endovascular therapy (EVT) preventing the development of malignant cerebral edema. We sought to characterize trends in DC in AIS between 2011 and 2020. Material and methodsWe performed a retrospective observational study of U.S. AIS hospitalizations using the National Inpatient Sample, 2011 to 2020. We calculated rates of DC per 10,000 AIS among all AIS hospitalizations, as well as AIS hospitalizations undergoing invasive mechanical ventilation (IMV). A logistic regression to determine predictors of DC was performed. ResultsOf ∼4.4 million AIS hospitalizations, 0.5 % underwent DC; of ∼300,000 AIS with IMV, 5.8 % underwent DC. From 2011 to 2020, the rate of DC increased from 37.4 to 59.1 per 10,000 AIS (p < 0.001). The rate of DC in patients undergoing IMV remained stable at ∼550 per 10,000 (p = 0.088). The most important factors predicting DC were age (OR 4.88, 95 % CI 4.53–5.25), hospital stroke volume (OR 2.61, 95 % CI 2.17–3.14), hospital teaching status (OR 1.54, 95 % CI 1.36–1.75), and transfer status (OR 1.53, 95 % CI 1.41–1.66); EVT status did not predict DC. ConclusionsThe rate of DC in AIS has increased between 2011 and 2020. Our findings are contrary to prior reports of decreasing DC rates over time. Increasing EVT rates do not seem to be preventing the occurrence of DC. Future research should focus on the decision-making process for both clinicians and surrogates regarding DC with consideration of long-term outcomes.

Abstract TP124: Evaluating Secondary Stroke Prevention Following Discharge From a Community Hospital

Background: Having major effects on both morbidity and mortality, stroke has become a large health burden worldwide. This disease state not only is the second leading cause of death; but also leaves about half of survivors chronically disabled. The 2021 AHA guidelines state that the risk of a recurrent stroke can be mitigated with appropriate secondary stroke prevention. The success of these interventions following discharge from the hospital largely lies in the hands of both the primary care physician and the patient. The goal of this investigation is to determine patient and provider compliance with risk factor modification and drug therapy within 3 months of hospitalization for acute ischemic stroke or transient ischemic attack. Methods: This quality improvement project is a single-center, retrospective chart review of the current secondary stroke prevention procedures exercised at a community hospital within a large healthcare system. This project has received Institutional Review Board approval. To be included, subject were required to have established primary care within the health system, discharged home following admission, and a final principle diagnosis of acute ischemic or transient ischemic event. The primary outcome assessed the percentage of patients that received a follow-up visit with a primary care provider within 30 days of hospital discharge. Additionally, this investigation also assessed modifiable risk factor management for secondary ischemic stroke prophylaxis. Results: Of the 97 patients that met inclusion criteria, 49 of them received a follow-up visit with a primary care provider within 30 days of hospital discharge (50.5%). In regards to secondary outcomes, all outcomes assessed showed to achieve appropriate clinical follow-up except for management of hypertension. It was reported that of the 49 patients, twenty-seven were reported to have controlled blood pressure at follow-up (55%). Conclusions: Results from the primary outcome of this quality improvement project highlighted the need for additional intervention to establish primary care prior to hospital discharge. Additionally this evaluation also highlighted further need for management of hypertension as a modifiable secondary risk factor.

Abstract WMP51: Patient-Related Factors and Social Determinants of Health Associated With Discharge to Home Following Acute Ischemic Stroke: Findings From the Get With the Guidelines Stroke Registry

Background: Medical comorbidities and stroke risk factors explain only a proportion of stroke incidence and outcomes in different populations. Our analysis aimed to determine if social determinants of health (SDOH) are associated with discharge home following acute ischemic stroke (AIS) hospitalization. Methods: The analyses included AIS patients hospitalized from January 1, 2015 to December 31, 2019 who were ambulating at baseline and had a known county of residence in the GWTG stroke registry. The primary outcome measure was discharge to home. County-level SDOH included income, education, owner-occupied home, unemployment, foreign-born, and insurance coverage and were the main predictors. Estimates of county-level SDOH were classified into quartiles, and the relative odds of outcome were assessed using a multivariable logistic regression. Results: Of 1,171,519 observations included in our analysis, median age was 71 years, 49% were female and 78% were of white race. As shown in the Table, demographic factors associated with lower likelihood of discharge home after AIS hospitalization included being female, black race, and age &gt;80 years. County-level SDOH factors associated with increased likelihood of discharge home included education (lowest vs highest quartile), owner occupied home (lowest vs highest quartile), foreign-born (lowest vs highest quartile), self-pay/no insurance (vs Medicare). Income (lowest vs highest quartile) and unemployment (lowest vs highest quartile) were associated with lower likelihood of discharge home. Conclusion: County-level SDOH are associated with discharge to home after AIS. Our findings can be used to develop interventions that reduce inequity in AIS outcomes.

Abstract TP228: Association of Dependent Cannabis Use in Patients With Chronic Liver Disease With Stroke Hospitalizations and Subsequent Mortality: A Nationwide Analysis

Introduction: Chronic liver disease (CLD) predisposes to systemic manifestations like thrombocytopenia and coagulopathy that can trigger stroke onset. Cannabis, due to its anti-inflammatory effects, could have a potential benefit for CLD patients. We aimed to study the impact of cannabis use disorder (CUD) or dependent use on stroke risk in CLD, considering recent American and Canadian surveys reporting 85% overlap between medicinal and recreational use. Methods: The National Inpatient Sample, 2019, was queried to identify adult stroke hospitalizations in patients with CLD. Two cohorts were created based on the presence of CUD. The primary outcomes were the rates and odds of stroke or acute ischemic stroke (AIS), with subsequent mortality in CUD vs. non-CUD cohorts. Secondary outcomes were resource utilization. Multivariable regression was controlled for patient-hospital-level factors and relevant comorbidities. Results: The CUD+ cohort had a lower rate of both overall stroke hospitalization (1.2% vs. 2.0%) and AIS hospitalization (0.8% vs. 1.2%) as compared to the CUD- cohort (p&lt;0.001). The median age of admissions for stroke and CLD with CUD was 58 years, whereas it was 64 years in the non-CUD cohort. Traditional CVD risk burden was lower, but uncomplicated hypertension, PVD, prior MI, and drug abuse were more prevalent in the CUD+ cohort. Patients with CLD and CUD showed lower odds of any stroke (OR: 0.61, 95% CI: 0.51-0.73; p &lt;0.001) and AIS (OR: 0.68, 95% CI: 0.55-0.85; p = 0.001) vs. the CUD- cohort. When adjusted for confounders, the odds of overall stroke risk were still lower (OR: 0.81; 95% CI: 0.66-0.98; p = 0.029) among the CUD+ cohort. However, adjusted odds for AIS showed no statistical significance (OR: 0.94; 95% CI: 0.74-1.19; p = 0.594). The all-cause mortality in the CUD+ cohort was lower compared to the CUD- cohort: 11.0% vs. 14.4%, p= 0.017, with shorter hospital stays and frequent routine discharges. Conclusion: This nationwide study revealed significantly reduced odds [20%] of stroke hospitalization in adults with CLD using cannabis on a regular, habitual basis. However, more prospective controlled studies are required to evaluate its impact on cardio-cerebrovascular risk with clarity on dose, duration, and mode of CUD in the long term.

Abstract WMP106: The Impact of Social Determinants of Health on Ambulatory Status at Discharge Following Acute Ischemic Stroke: Findings From the Get With the Guidelines-Stroke Registry

Background: Medical comorbidities and stroke risk factors only explain a proportion of stroke incidence and outcomes in different populations. Social determinants of health(SDOH)have been associated with incident stroke. The objective of our analysis was to determine if SDOH are associated with ambulatory status at discharge following acute ischemic stroke(IS) hospitalization. Methods: We included IS patients hospitalized from January 1, 2015-December 31, 2019 who were ambulating at baseline and had known county of residence in the GWTG registry. The primary outcome measure was ambulatory status at discharge, defined as ability to ambulate with or without the assistance of a device or person. Estimates of SDOH including education status, income, employment status, poverty and foreign-born residents at patients’ residence county were the main predictors. Baseline demographics, clinical comorbidities, stroke center certification status among other logistic and event-related factors were analyzed. Covariates included demographic, clinical factors and hospital-related factors. Estimates of county level SDOH were classified into quartiles and the relative odds of outcome were assessed using a multivariable logistic regression. Results: Of 1,171,519 observations included in our final analysis, median age was 71 years, 49% were female, 78% were of white ethnicity and 45% were insured through Medicaid/Medicare. In multivariable logistic regression analysis adjusting for baseline characteristics, counties with the lowest quartile education level had a lower likelihood of being ambulatory at discharge than the highest quartile (OR0.91[95%CI 0.86-0.96],p=0.001).Patients from counties with the lowest quartile of foreign-born residents were more likely to be ambulatory at discharge than the highest quartile (OR1.11[95%CI 1.05-1.18];P=0.001). Income, employment status, and poverty were not associated with ambulatory status at discharge. Conclusion: County level SDOH including education and percentage of foreign born population were associated with ambulatory status at discharge after ischemic stroke hospitalization. Our findings can be used to develop interventions that reduce inequity in ischemic stroke outcomes at discharge.

Abstract TMP21: Hospital Characteristics Influencing Discharge Disposition Following Acute Stroke: Findings From the Get With the Guidelines-Stroke Registry

Background: Medical comorbidities and stroke risk factors explain only a proportion of stroke incidence and outcomes in different populations. Our analysis aimed to determine if hospital characteristics are associated with discharge home following acute ischemic stroke (AIS) hospitalization. Methods: The analyses included AIS patients hospitalized from January 1, 2015 to December 31, 2019 who were ambulating at baseline. The primary outcome measure was discharge to home. Hospital-level characteristics including time and day of arrival, location of stroke onset, transport mode, hospital bed size and stroke center certification status. The relative odds of outcome were assessed using a multivariable logistic regression. Results: Of 1,171,519 observations included in our analysis, median age was 71 years, 49% were female and 78% were of white race. As shown in the Table, factors associated with lower odds of home discharge included night-time arrival, stroke onset in a chronic care facility, arrival by ambulance, geographic location, and no stroke center certification; these factors were independent of social determinants of health such as education, income, employment status, poverty, and frequency of foreign-born residents at patients’ residence county. There was a trend towards improved outcomes over the study period. Conclusion: Hospital level characteristics influence likelihood of home discharge after AIS, independent of social determinants of health.

Abstract WMP60: Comparison of Demographic and Clinical Characteristics and the CDC Social Vulnerability Index Among Medicare Beneficiaries Hospitalized With Acute Ischemic Stroke, April 2020 - December 2021

Introduction: Extensive evidence shows that social inequities create health disparities. However, limited information exists on how demographic and clinical factors are associated with social inequities among older patients hospitalized with acute ischemic stroke (AIS) during COVID-19. Methods: We analyzed data on Medicare fee-for-service beneficiaries aged ≥65 years hospitalized with AIS from April 1, 2020, to December 31, 2021. All patients were followed until March 31, 2023. We used US Centers for Disease Control and Prevention’s 2020 Social Vulnerability Index (SVI) and compared demographic and clinical features by SVI tertiles (low 0-0.33, moderate 0.34-0.66, high 0.67-1.0). Results: Among 249299 Medicare FFS beneficiaries with AIS, there were 57814 (23.2%) with low, 88565 (35.5%) moderate, and 102920 (41.3%) high SVI. Demographic and clinical features differed significantly across SVI tertiles. Compared to AIS patients living in low SVI communities, patients living in high SVI areas were significantly younger (median age 79.0 vs 79.9 years), more likely to be non-Hispanic Black (15.4% vs 4.3%), had more severe stroke at admission per National Institutes of Health Stroke Scale (NIHSS) score (9.4% NIHSS ≥20 vs 8.4%), more history of COVID-19 (7.7% vs 6.3%), higher proportion of death at the end of follow-up (40.4% vs 38.2%), and more comorbidities. Conclusion: Medicare patients with AIS hospitalizations live in communities with higher SVI. These data identified racial disparities and more severe outcomes among AIS patients living in areas with higher social vulnerabilities, signaling a need for multisectoral interventions and policies that impact AIS outcomes.

Plateauing atrial fibrillation burden in acute ischemic stroke admissions in the United States from 2010 to 2020.

Utilization of oral anticoagulants for acute ischemic stroke (AIS) prevention in patients with atrial fibrillation (AF) increased in the United States over the last decade. Whether this increase has been accompanied by any change in AF prevalence in AIS at the population level remains unknown. The aim of this study is to evaluate trends in AF prevalence in AIS hospitalizations in various age, sex, and racial subgroups over the last decade. We used data contained in the 2010-2020 National Inpatient Sample to conduct a serial cross-sectional study. Primary AIS hospitalizations with and without comorbid AF were identified using International Classification of Diseases Codes. Joinpoint regression was used to compute annualized percentage change (APC) in prevalence and to identify points of change in prevalence over time. Of 5,190,148 weighted primary AIS hospitalizations over the study period, 25.1% had comorbid AF. The age- and sex-standardized prevalence of AF in AIS hospitalizations increased across the entire study period 2010-2020 (average APC: 1.3%, 95% confidence interval (CI): 0.8-1.7%). Joinpoint regression showed that prevalence increased in the period 2010-2015 (APC: 2.8%, 95% CI: 1.9-3.9%) but remained stable in the period 2015-2020 (APC: -0.3%, 95% CI: -1.0 to 1.9%). Upon stratification by age and sex, prevalence increased in all age/sex groups from 2010 to 2015 and continued to increase throughout the entire study period in hospitalizations in men 18-39 years (APC: 4.0%, 95% CI: 0.2-7.9%), men 40-59 years (APC: 3.4%, 95% CI: 1.9-4.9%) and women 40-59 years (APC: 4.4%, 95% CI: 2.0-6.8%). In contrast, prevalence declined in hospitalizations in women 60-79 (APC: -1.0%, 95% CI: -0.5 to -1.5%) and women ⩾ 80 years over the period 2015-2020 but plateaued in hospitalizations in similar-aged men over the same period. AF prevalence in AIS hospitalizations in the United States increased over the period 2010-2015, then plateaued over the period 2015-2020 due to declining prevalence in hospitalizations in women ⩾ 60 years and plateauing prevalence in hospitalizations in men ⩾ 60 years.

Abstract 13614: Nationwide Trends in Transcranial Doppler Utilization During Acute Ischemic Stroke Hospitalizations

Background: Trans-cranial Doppler (TCD), diagnostic ultrasound of the head and neck is a non-invasive, safe, and portable tool to assess dynamic cerebral blood flow. TCD allows us to explore the patient's neurocritical pathological features without invasive testing. Although TCD is portable and inexpensive compared to CT/MR angiograms, its utilization during AIS hospitalization is nonfrequent and unknown. Aim: The aim of the study was to evaluate the patterns of TCD use during AIS hospitalizations. Design/Methods: Data from the Nationwide Inpatient Sample (NIS-2003-2014) for adults (≥18 yr) were analyzed. Primary discharge diagnoses of AIS and TCD were identified using ICD-9-CM codes 433-436, 437.1, and 88.71, respectively. Cochran-Armitage trend test and multivariable survey logistic regression were utilized to evaluate TCD use and predictors. Results: Of 4,224,924 patients identified with AIS 93,673 (2.22%) had TCD examination. There was a significant decline in utilization of TCD (3.84% in 2003 to 1.34% in 2014, p&lt;0.0001). The patients with TCD utilization had a higher mean length of stay (6 vs 5 days; p&lt;0.0001) and cost of hospitalization ($39,270 vs $38,100; p=0.0007) than non-TCD utilization. In multivariate regression analysis, age group 50-64 (aOR:1.55; 95%CI:1.28-1.88), 65-79 (1.66; 1.32-2.08), ≥80 (1.68; 1.29-2.18), African American (1.51; 1.45-1.58), Hispanic (1.63; 1.55-1.72), Asian/Pacific Islander (1.36; 1.26-1.47), zip income 76-100th percentile (1.24; 1.19-1.30), large bed size hospitals (1.44; 1.36-1.52), hypertension (1.05; 1.01-1.09), hypercholesterolemia (1.23; 1.18-1.29; p&lt;0.0001), alcohol abuse (1.09; 1.00-1.18), anticoagulant use (1.47; 1.39-1.56), ischemic heart disease (1.05; 1.01-1.09), and ventricular septal defect (2.69; 1.31-5.52) have higher odds of TCD utilization. We have noticed lower odds of TCD utilization in elective admissions (0.65; 0.59-0.72). (c-statistic: 0.71) Conclusions: Over the last decade, there has been a slight but steady decrease in the use of TCD during AIS hospitalizations in the US. Future studies should examine the cost-utility of TCD, especially with the advent of endovascular stroke treatment systems.

Abstract 16187: COVID-19 and Outcomes of Acute Ischemic Stroke - A Nationwide Cross-Sectional Study

Introduction: Acute ischemic stroke (AIS) is thesecond leading cause of death globally, accounting for approximately 11% of alldeaths, long-term disability, and functional impairments in survivors. TheCOVID-19 pandemic has raised concerns about its impact on AIS patients. Aim: This study aimed to assess the outcomes,including mortality and severity of disability in AIS hospitalizations withCOVID-19. Methods: We performed a retrospective cross-sectionalanalysis of the Nationwide Inpatient Sample (NIS-2020) in adulthospitalizations for AIS to compare the outcomes [death &amp; APRDRGseverity/disability] in COVID-19 patients using ICD-10 codes. We performedweighted analyses using chi-square, unpaired t-test, and multivariate logisticregression models to evaluate COVID-19-associated poor outcomes amongst AISpatients. Results: Out of 504,460 AIS patients, 7,590 had AIStriggered by COVID-19. Amongst AIS hospitalizations, COVID-19 was more frequentin age group &gt;65 year old 63.2%, male 52.6%, White race (51.4%), patientwith Medicare (58.7%), median household income 0-25 percentile (33.6%), Southzone (43.4%), and hypertensives (83.7%). AIS patients with COVID-19 had ahigher mortality (10.93% vs 3.8%) and severe/extreme disability (93.21% vs37.43%) rates in comparison to patients without COVID-19. (p&lt;0.0001) Inregression analysis COVID-19 was associated with 213% higher odds of mortality(aOR: 3.13, 95% CI: 2.90-3.38, p&lt;0.0001, c:0.671) and higher odds of severe/extreme disability(26.85, 24.53-29.39, p&lt;0.0001, c:0.686) compared to AIS patients withoutCOVID-19. Conclusion: These findings emphasize the substantialimpact of COVID-19 on AIS patients by elevating mortality and risk of severedisability compared to their counterparts. Efforts should be directed towards earlyidentification of stroke population that is at higher risk ofCOVID-19-associated poor outcome and prompt management tomitigate the burden of the both diseases.

Abstract 18180: Contemporary Nationwide Trends in Major Adverse Cardiac and Cerebrovascular Events in Young Hospitalized Adults With Dependent Cannabis Use in Absence of Concomitant Tobacco, Alcohol or Cocaine Use Disorder, 2016-2019

Introduction: Recreational cannabis use has been on the rise among young adults in recent years. Dependent cannabis use disorder (CUD) has been linked to various cardiac events, but its impact on young adults in the absence of concomitant substance abuse remains unclear. We aim to analyze the nationwide trends in hospitalizations for major adverse cardiac and cerebrovascular events (MACCE) in this specific population. Methods: We identified hospitalized young adults (18-44 years) using National Inpatient Sample (2016 -2019), excluding those with concomitant substance abuse (tobacco, alcohol, and cocaine). They were divided into CUD+ and CUD- groups. We assessed the trends in hospitalizations for MACCE, including all-cause mortality (ACM), acute myocardial infarction (AMI), cardiac arrest (CA), and acute ischemic stroke (AIS), using ICD 10 codes. Results: Of 27.4 million hospitalizations among young adults without other substance abuse, 4.2% (1.1 million) had CUD. The rates of hospitalizations for MACCE (1.71% vs. 1.35%), AMI (0.86% vs. 0.54%), CA (0.27% vs. 0.24%), and AIS (0.27 vs. 0.24%), were higher in the CUD+ group compared to the CUD- group (P &lt; 0.001). However, the rate of ACM hospitalizations (0.30% vs. 0.44%) were lower in the CUD+ group. From 2016 to 2019, the CUD+ group exhibited a relative increase of 5% in MACCE and 20% in AMI hospitalizations, which were lower compared to the respective increases of 22% and 36% in the CUD- group (Ptrend&lt;0.05). Additionally, there was a relative decrease of 13% in ACM hospitalizations among the CUD+ group, whereas the CUD- group experienced a relative increase of 10% (Ptrend&lt;0.05). Conclusion: The CUD+ group had higher rates of MACCE admissions, but the growing trends were more pronounced in the CUD- group through the years. Interestingly, the CUD+ group exhibited lower rates of ACM compared to the CUD- group. Further research is needed to better understand this complex relationship.

Abstract 17538: The Weekend Effect on In-Hospital Outcomes of Elderly Patients With Acute Ischemic Stroke and Concurrent COVID-19 Infection: A Nationwide Multicenter Study

Background: Acute ischemic stroke (AIS) and COVID-19 are individually associated with poor outcomes. The impact of the pandemic on the US healthcare system, including staff shortages and disparities, may have delayed timely interventions and adherence to guidelines. We investigated the Weekend Effect on outcomes in elderly patients with AIS and COVID-19 to better understand its relationship during the challenging pandemic period. Methods: Using ICD-10-CM codes, we analyzed AIS and COVID-19 hospitalizations among the elderly (&gt;65 years) from the 2020 National Inpatient Sample. Weekday and weekend admissions were compared for baseline characteristics, comorbidities, and outcomes. The multivariable analysis was adjusted for confounding variables. A two-tailed p&lt;0.05 was considered significant. Results: Of 14,070 total AIS and concurrent COVID-19 admissions among the elderly, 10,425 were on weekdays, and 3645 were on weekends. While both cohorts exhibited comparable age distributions, the weekend admissions had a higher percentage of females (47.1% vs. 45.2%) and whites (59.5% vs. 58.1%). They had a higher prevalence of hypertension (82.2% vs. 78.6%), hyperlipidemia (52.9% vs. 50.1%), chronic pulmonary disease (19.1% vs. 17%), obesity (15% vs. 13.6%), depression (10.2% vs. 8.2%). Additionally, all-cause mortality (33.5% vs. 32.5%) and cardiogenic shock (1.9% vs. 1.7%) were slightly higher among weekend admissions. Upon adjusting for confounding factors, the overall mortality rate among weekend admissions showed no significant association, aOR-1.15 [95%CI:0.42-0.96; p-0.169]. Conclusion: Although there is a higher prevalence of comorbidities and overall mortality among weekend admissions, no significant association between the Weekend Effect and poor in-hospital outcomes in elderly COVID-19 patients with AIS was noted. However, ensuring adequate staffing and resource availability during weekends may enhance the quality of care provided.

The Mediterranean Soul Food Diet Intervention After Stroke, a Feasibility Study in the Stroke Belt

The Mediterranean diet has positive effects on primary and secondary prevention of cardiovascular disease including stroke, yet dietary counseling to stroke patients is under-utilized. This study aimed to develop a culturally adapted Mediterranean diet and introduce it to patients admitted to the hospital for acute ischemic stroke with at least one metabolic risk factor (type 2 diabetes mellitus [DM], hypertension [HTN], high low-density lipoprotein [LDL], low high-density lipoprotein [HDL], and/or body mass index [BMI] &gt; 25). Dietary adherence and nutritional knowledge were measured at baseline and 30, 90, and 120 days post-stroke. Weight, hemoglobin A1C [HbA1C], and triglycerides [TG] were assessed at baseline and follow-up. The study enrolled 54 participants, 50 of whom had sufficient data for analysis. Dietary adherence and nutritional knowledge scores increased in 76.4% of participants, with a statistically significant median increase for each. Additionally, participants had significantly lower weight, HbA1C, and TG at follow-up than baseline. This study showcases the potential to introduce a culturally appropriate Mediterranean diet at the point-of-care, and significantly influence dietary adherence and nutritional knowledge and multiple stroke risk factors.

Effect of chronic antiplatelet therapy on clinical outcomes of endovascular thrombectomy for treatment of acute ischemic stroke.

The objective of this study was to investigate the prognostic significance of chronic antiplatelet therapy (APT) usage in acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT). Long-term APT may enhance recanalization but may also predispose patients to an increased risk of hemorrhagic transformation. Weighted hospitalizations for anterior-circulation AIS treated with EVT were identified in a large United States claims-based registry. Baseline clinical characteristics and outcomes were compared between patients with and without chronic APT usage prior to admission. Multivariable logistic regression analysis was performed to assess adjusted associations between APT and study endpoints. This analysis identified 36,560 patients, of whom 8170 (22.3%) were on a chronic APT regimen prior to admission. These patients were older and demonstrated a higher burden of comorbid disease, but had similar stroke severity on presentation in comparison with those not on APT. On unadjusted analysis, patients with prior APT demonstrated higher rates of favorable outcomes (24.3% vs 21.5%, p < 0.001), lower rates of mortality (7.0% vs 10.1%, p < 0.001), and lower rates of any intracranial hemorrhage (ICH; 20.3% vs 24.2%, p < 0.001), but no difference in rates of symptomatic ICH (sICH). Following multivariable adjustment for baseline clinical characteristics including age, acute stroke severity, and comorbidity burden, prior APT was associated with favorable outcome (adjusted odds ratio [aOR] 1.21, 95% CI 1.17-1.24, p < 0.001) and a lower likelihood of mortality (aOR 0.73, 95% CI 0.70-0.77, p < 0.001), without an increased likelihood of ICH (any ICH aOR 0.84, 95% CI 0.81-0.87, p < 0.001; sICH aOR 0.92, 95% CI 0.82-1.03, p = 0.131). Retrospective evaluation of patients with AIS treated with EVT using registry-based data demonstrated an association of prior APT usage with favorable outcomes, without an increased risk of hemorrhagic transformation.

Prevalence and Outcomes of Depression, Obstructive Sleep Apnea, and Concurrent Anxiety (DOCA) in Stroke Survivors: Insights From a Nationwide Study.

Many individuals will also experience psychological side effects after a stroke episode, such as symptoms of depression, anxiety (generalized anxiety disorder (GAD)), and/or specific phobias, considerably decreasing their quality of life (QOL). This study aimed to evaluate the prevalence of depression, obstructive sleep apnea (OSA), and concurrent anxiety (DOCA) and their outcomes (morbidity, disability (All Patient Refined Diagnosis Related Group (APRDRG) - loss of function), and discharge disposition) among acute ischemic stroke (AIS) hospitalizations. A cross-sectional study used the National Inpatient Sample (NIS) from 2003-2017. Adults with hospitalizations with AISwere extracted, and DOCA was identified using ICD-9/10-CM codes. Weighted analysis using a chi-square test and mixed-effect multivariable survey logistic regression was used to assess the prevalence and role of DOCA in predicting outcomes. Out of 5,690,773 AIS hospitalizations, 2.7%, 3.1%, and 4.4% had depression, OSA, and GAD, respectively. In AIS patients, females had a higher prevalence of depression (3.4% vs. 2.3%) and GAD (5.9% vs. 3.0%) and a quality of life lower prevalence of OSA (2.2% vs 4.4%) in comparison to males (p<0.0001). Caucasians had a higher prevalence of depression, OSA, and GAD in comparison to others (African Americans/Hispanics/Asians/Native Americans). Depressed patients had a higher prevalence of morbidity (9%vs. 8%vs5%vs. 7%), disability (46% vs. 46% vs. 35% vs. 37%), transfer to non-home (69% vs. 58% vs. 61% vs. 63%) in comparison with OSA, GAD, and non-DOCA patients, respectively (p<0.0001). Depression was associated with a 40% higher chance of severe disability (aOR 1.40; 95% CI 1.38-41), morbidity (1.36; 1.33-1.38), and discharge to non-home (1.54; 1.52-1.56). OSA and GAD had higher odds of non-home discharge amongst post-AIS hospitalizations. DOCA is associated with poor outcomes among post-AIS patients. Prompt recognition by screening and timely management of DOCA may mitigate the adverse outcomes.

Cardiovascular hospitalizations for Medicare advantage beneficiaries in the United States, 2009 to 2019

Federal programs measuring hospital quality of care for acute cardiovascular conditions are based solely on Medicare fee-for-service (FFS) beneficiaries, and exclude Medicare Advantage (MA) beneficiaries. In this study we characterize the proportion of Medicare beneficiaries enrolled in MA at the time of acute myocardial infarction (AMI), heart failure (HF), and ischemic stroke hospitalization. Retrospective cross-sectional study of short-term acute care hospitals using Medicare claims in 2009 and 2019. There were 2,653 hospitals in 2009 and 2,732 hospitals in 2019. Across hospitals, the proportion of Medicare beneficiaries hospitalized for AMI who were enrolled in MA increased between 2009 (hospital-level median 14.4% [IQR 5.1%-26.0%]) and 2019 (33.3% [IQR 20.6%-45.2%]), with substantial variation across hospitals. Similar patterns were observed for HF (13.0% [IQR 5.3%-24.3%] to 31.0% [IQR 20.2%-42.3%]) and ischemic stroke (14.6% [IQR 5.3%-26.7%] to 33.3% [IQR 20.9%-46.0%]). Within each hospital referral region, hospital size (large 36.3% vs small 24.5%; adjusted difference 6.7%, 95% CI, 4.5%-8.8%), teaching status (teaching 34.5% vs nonteaching 28.2%; 2.8%, 1.4%-4.1%), and ownership status (private nonprofit 32.3% vs public 24.5%; 5.2%, 3.5%-6.9%) were each associated with a higher hospital MA proportion. The proportion of Medicare beneficiaries hospitalized for AMI, HF, and ischemic stroke enrolled in MA doubled between 2009 and 2019, with substantial variation across hospitals. These findings have implications for federal efforts to measure and improve quality, which currently focus only on FFS beneficiaries.

Seasonal variation in the incidence of primary intracerebral hemorrhage: a 16-year nationwide analysis.

Data on nationwide trends and seasonal variations in the incidence of Intracerebral Hemorrhage (ICH) in the United States (US) are lacking. We used the Nationwide Inpatient Sample (2004-2019) and Census Bureau data to calculate the quarterly (Q1:January-March; Q2:April-June; Q3:July-September; Q4:October-December) incidence rates (IR) of adult (≥18 years) ICH hospitalizations, aggregated across Q1-Q4 and Q2-Q3. We report adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CI) for differences in the quarterly incidence of ICH, as compared to acute ischemic stroke (AIS), between Q1Q4 and Q2Q3 using a multivariable Poisson regression model. We additionally performed stratified analyses across the four US regions. Among 822,143 (49.0% female) ICH and 6,266,234 (51.9% female) AIS hospitalizations, the average quarterly crude IR of ICH was consistently higher in Q1Q4 compared to Q2Q3 (5.6 vs. 5.2 per 100,000) (aIRR, CI: 1.09, 1.08-1.11)-this pattern was similar across all four US regions. However, a similar variation pattern was not observed for AIS incidence. The incidence (aIRR, CI) of both ICH (1.01, 1.00-1.02) and AIS (1.03, 1.02-1.03) is rising. Unlike AIS, ICH incidence is consistently higher in colder quarters, underscoring the need for evaluation and prevention of factors driving seasonal variations in ICH incidence.

Relationships among hospital acute ischemic stroke volumes, hospital characteristics, and outcomes in the US

Background and ObjectivesPrior research on volume-based patient outcomes related to acute ischemic stroke (AIS) have demonstrated contradictory results and fail to reflect recent advances in stroke care. We sought to examine contemporary relationships between hospital AIS volumes and outcomes. MethodsWe used complete Medicare datasets in a retrospective cohort study using validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined several hospital characteristics by AIS volume quartile. We performed adjusted logistic regressions testing associations of AIS volume quartiles with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home, and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, MDI, hospital urban-rural designation, stroke certification status and ICU and neurologist availability at the hospital. ResultsThere were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1-8 AIS admissions; 2nd: 9-44; 3rd: 45-237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p<0.0001), with ICU bed availability (19.8% vs 4.1%, p<0.0001) and with neurologist expertise (91.1% vs 3%, p<0.0001). In the highest AIS quartile (compared to the lowest quartile), there was lower inpatient mortality (odds ratio [OR] 0.71 [95%CI 0.57-0.87, p<0.0001]), lower 30-day mortality (0.55 [0.49-0.62], p<0.0001), greater receipt of tPA (6.60 [3.19-13.65], p<0.0001) and ET (16.43 [10.64-25.37], p<0.0001, and greater likelihood of discharge home (1.38 [1.22-1.56], p<0.0001). However, when the highest quartile hospitals were examined separately, higher volumes were associated with higher mortality despite higher rates of tPA and ET receipt. ConclusionsHigh AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. These features likely play a role in the better outcomes observed at such centers, including inpatient and 30-day mortality and discharge home. However, the highest volume centers had higher mortality despite greater receipt of interventions. Further research is needed to better understand volume-outcome relationships in AIS to improve care at lower volume centers.