Stroke Unit Admission Research Articles

The Montreal Cognitive Assessment detects cognitive deficits that go unnoticed during clinical observation in the acute phase after stroke

ABSTRACT Background Detecting cognitive impairments early after stroke is essential for appropriate referrals. Although recommended in stroke guidelines, early cognitive screening is not always implemented. We assessed whether the Montreal Cognitive Assessment (MoCA) adds diagnostic value compared to clinical observation alone. In addition, discharge destinations for stroke patients with and without cognitive deficits detected with the screening tool or the treatment team were explored. Methods Forty-four stroke patients were screened with the MoCA during stroke unit admission. Their charts were studied for cognitive impairments reported by the stroke care team, who were blinded to screening scores. Proportions of detected cognitive deficits were compared between screening (score <26) and patient charts. Discharge destination distribution (home vs. rehabilitation) was explored. Results The proportion of cognitively impaired patients indicated by the MoCA (84%) and reported in patients’ charts (25%) differed significantly (p < 0.001). The distribution of discharge destination did not suggest an association with the detection of cognitive deficits by the treatment team or the cognitive screening. Conclusions The MoCA detects more cognitive deficits than clinical impression alone, emphasizing the importance of standard screening for cognitive impairments in acute stroke patients. Ultimately, systematic screening may enhance discharge planning and improve long-term outcomes.

Do implementation interventions improve evidence-based care in acute stroke settings? A Cochrane Review summary with commentary.

Evidence on acute stroke management is continuously growing. Stroke units are often associated with better access to high-level evidence-based practices, but even there, recommendations can be inconsistently delivered to patients with stroke. Implementation interventions are strategies designed to improve the application of evidence-based care. To provide a commentary on the Cochrane Review by Lynch et al. on the effects of implementation interventions on adherence to evidence-based recommendations by health professionals working in acute stroke units. A systematic search was performed in CENTRAL, MEDLINE, Embase, and other databases. The search was also performed in grey literature databases, trial registries, systematic reviews and primary studies, as well as in the reference list of identified studies. The review included seven cluster-randomized trials (with 42,489 participants). Studies compared the implementation of strategies composed of different parts (multifaceted) to no intervention, or a multifaceted strategy vs another intervention. These strategies were aimed at changing and improving the delivery of care in the hospital. It included health professional participants, such as nurses, physicians and allied health professionals. The authors concluded that there was uncertainty whether implementation strategies compared with no intervention have any effect on patients receiving evidence-based care during their stroke unit admission. Implementation interventions compared to no intervention probably have little or no effect on the risk of patients dying or being disabled or dependent, and probably do not change patients' hospital length of stay. Due to the very low certainty of evidence, there is uncertainty whether a multifaceted implementation intervention, compared to no intervention, can improve adherence to evidence-based recommendations in acute stroke settings.

Management of delirium in acute stroke patients: a position paper by the Austrian Stroke Society on prevention, diagnosis, and treatment.

Delirium is a common complication in acute stroke patients, occurring in 15-35% of all stroke unit admissions and is associated with prolonged hospital stay and a poor post-stroke prognosis. Managing delirium in acute stroke patients necessitates an intensive and multiprofessional therapeutic approach, placing a significant burden on healthcare staff. However, dedicated practical recommendations for delirium management developed for the population of acute stroke patients are lacking. For this purpose, the Austrian Stroke Society, in cooperation with the Austrian Society of Neurology, the Austrian Society of Neurorehabilitation, and the Austrian Society of Psychiatry, Psychotherapy, and Psychosomatics has formulated an evidence-based position paper addressing the management of delirium in acute stroke patients. The paper outlines practical recommendations on the three pillars of care in stroke patients with delirium: (a) Key aspects of delirium prevention including stroke-specific delirium risk factors and delirium prediction scores are described. Moreover, a non-pharmacological delirium prevention bundle is presented. (b) The paper provides recommendations on timing and frequency of delirium screening to ensure early diagnosis of delirium in acute stroke patients. Moreover, it reports on the use of different delirium screening tools in stroke populations. (c) An overview of non-pharmacological and pharmacological treatment strategies in patients with delirium and acute stroke is presented and summarized as key recommendation statements.

Factors associated with receiving neurologist-led stroke unit admission: 10-year retrospective study of administrative data of hospitalized stroke in Alberta, Canada

Factors associated with receiving neurologist-led stroke unit admission: 10-year retrospective study of administrative data of hospitalized stroke in Alberta, Canada

Machine learning using multimodal and autonomic nervous system parameters predicts clinically apparent stroke-associated pneumonia in a development and testing study.

Stroke-associated pneumonia (SAP) is a preventable determinant for poor outcome after stroke. Machine learning (ML) using large-scale clinical data warehouses may be able to predict SAP and identify patients for targeted interventions. The aim of this study was to develop a prediction model for identifying clinically apparent SAP using automated ML. The ML model used clinical and laboratory parameters along with heart rate (HR), heart rate variability (HRV), and blood pressure (BP) values obtained during the first 48h after stroke unit admission. A logistic regression classifier was developed and internally validated with a nested-cross-validation (nCV) approach. For every shuffle, the model was first trained and validated with a fixed threshold for 0.9 sensitivity, then finally tested on the out-of-sample data and benchmarked against a widely validated clinical score (A2DS2). We identified 2390 eligible patients admitted to two-stroke units at Charité between October 2020 and June 2023, of whom 1755 had all parameters available. SAP was diagnosed in 96/1755 (5.5%). Circadian profiles in HR, HRV, and BP metrics during the first 48h after admission exhibited distinct differences between patients with SAP diagnosis vs. those without. CRP, mRS at admission, leukocyte count, high-frequency power in HRV, stroke severity at admission, sex, and diastolic BP were identified as the most informative ML features. We obtained an AUC of 0.91 (CI 0.88-0.95) for the ML model on the out-of-sample data in comparison to an AUC of 0.84 (CI 0.76-0.91) for the previously established A2DS2 score (p < 0.001). The ML model provided a sensitivity of 0.87 (CI 0.75-0.97) with a corresponding specificity of 0.82 (CI 0.78-0.85) which outperformed the A2DS2 score for multiple cutoffs. Automated, data warehouse-based prediction of clinically apparent SAP in the stroke unit setting is feasible, benefits from the inclusion of vital signs, and could be useful for identifying high-risk patients or prophylactic pneumonia management in clinical routine.

Predictive Factors for Hemorrhagic Transformation in Acute Ischemic Stroke in the REAL-World Clinical Practice.

Few data exists on predictive factors of hemorrhagic transformation (HT) in real-world acute ischemic stroke patients. The aims of this study were: (i) to identify predictive variables of HT (ii) to develop a score for predicting HT. We retrospectively analyzed the clinical, radiographic, and laboratory data of patients with acute ischemic stroke consecutively admitted to our Stroke Unit along two years. Patients with HT were compared with those without HT. A multivariate logistic regression analysis was performed to identify independent predictors of HT on CT scan at 24 hours to develop a practical score. The study population consisted of 564 patients with mean age 77.5±11.8 years. Fifty-two patients (9.2%) showed HT on brain CT at 24 hours (4.9% symptomatic). NIHSS score ≥8 at Stroke Unit admission (3 points), cardioembolic etiology (2 points), acute revascularization by systemic thrombolysis and/or mechanical thrombectomy (1 point), history of previous TIA/stroke (1 point), and major vessel occlusion (1 point) were found independent risk factors of HT and were included in the score (Hemorrhagic Transformation Empoli score (HTE)). The predictive power of HTE score was good with an AUC of 0.785 (95% CI: 0.749-0.818). Compared with 5 HT predictive scores proposed in the literature (THRIVE, SPAN-100, MSS, GRASPS, SITS-SIC), the HTE score significantly better predicted HT. NIHSS score ≥8 at Stroke Unit admission, cardioembolism, urgent revascularization, previous TIA/stroke, and major vessel occlusion were independent predictors of HT. The HTE score has a good predictive power for HT. Prospective studies are warranted.

Gapless Electrocardiogram-Monitoring in stroke at high risk of atrial fibrillation.

Previous studies investigating prolonged electrocardiogram (ECG)-monitoring after ischemic stroke had significant gaps between the index event and the beginning of long-term monitoring. Atrial fibrillation (AF) detection might be higher if prolonged cardiac rhythm documentation is performed with a gapless approach without any interruption of monitoring time. This investigator-initiated, prospective study included patients with acute ischemic stroke or transient ischemic attack at three study centers. Participants received gapless ECG-monitoring via telemetry during stroke-unit admission until implantation of an insertable cardiac monitor (ICM) within the first days after the index event. Patients acted as their own controls and also received standard 24-72-h Holter ECG. A total of 110 patients were included, of whom 86 (78.2%) had an embolic stroke of unknown source, 14 (12.7%) had small-vessel disease, and 10 (9.1%) had large-artery disease. AF was newly diagnosed in 17 (15.5%) patients via ICM monitoring, compared to one (0.9%) patient via Holter ECG during 6 months of follow-up (p< 0.001). The detection rate of AF within the first 30 days was 10.0%, which accounted for 64% of all new AF diagnoses. The median duration of the detected episodes was 1.7 (interquartile range=0.2-4.7) h. All patients with new onset AF were treated with oral anticoagulation. Gapless ECG-monitoring is an effective strategy to significantly increase the detection rate of AF after ischemic stroke. This finding supports the use of long-term ECG-monitoring with a gapless approach without any interruption in monitoring time as the gold standard for clinical practice.

1186 IMPROVED PERFORMANCE AGAINST SSNAP PARAMETERS FOR THROMBOLYSED STROKE PATIENTS FOLLOWING CHANGES IN PRACTICE

Abstract Background The CQC inspection of the Royal Lancaster Infirmary (RLI) in May 2021 rated the performance of the stroke department unsatisfactory, leading to a number of changes. A retrospective audit was performed to determine the impact of these changes for thrombolysed stroke patients. Aim This retrospective audit assessed the performance of the stroke department at the RLI against the parameters set by the ‘Sentinel Stroke National Audit Program’ (SSNAP), comparing 6-month periods before and after the CQC inspection in May 2021. Method Using electronic medical records and SSNAP data, we reviewed every thrombolysed stroke patient at the RLI between November 2020 until April 2021 and from May 2021 until November 2021, assessing 10 parameters and comparing the results with SSNAP targets. Since May 2021, changes to practice introduced included opening a new, larger stroke unit located directly opposite the Emergency Department, ring-fencing stroke beds, doubling the number of stroke specialists and stroke consultants reviewing all suspected stroke patients face-to-face within working hours. Results 46 patients were thrombolysed with 42 confirmed as having had ischaemic strokes on subsequent MRI imaging. All patients were discussed with a stroke consultant before thrombolysis. Mean time from arrival to CT improved from 51 to 34.5 minutes, admission to stroke unit from 7hr53 to 4hr36 and to thrombolysis from 2hr18 to 1hr22. The number of thrombolysis complications decreased from 5 to 2. Since the changes, the SSNAP grade for stroke unit admission improved from C to A and specialist assessments from E to B. Conclusion The changes implemented following the May 2021 CQC inspection have had a positive impact on the care of thrombolysed stroke patients and overall SSNAP grades at RLI. Improvements are still required and the next steps include improving the efficiency of thrombolysis times and further improving SSNAP grades.

Processes of Care and Associated Factors in Patients With Stroke by Immigration Status.

Receiving evidence-based stroke care processes is associated with good clinical outcome. However, data on early stroke care among immigrants are scarce. We investigated whether guideline-recommended acute stroke care and associated factors differ between immigrants and Danish-born residents. Patients admitted with ischemic and hemorrhagic stroke diagnoses (n=129,724) between 2005 and 2018 were identified from the Danish Stroke Registry. We included 123,928 Danish-born residents and 5796 immigrants with stroke. Compared with Danish-born residents, immigrants were less likely to be admitted to a stroke unit within 24 hours after stroke onset (81.5% vs. 83.9%, P <0.001) and had lower odds of early stroke care including dysphagia screening, physiotherapy, occupational therapy, and nutritional assessment. After adjustment for age, sex, clinical, and sociodemographic factors, immigrants had lower odds of early stroke unit admission (odds ratio [OR]: 0.97; 95% CI, 0.94-0.99), early dysphagia screening (OR: 0.96; 95% CI, 0.93-0.98), early physiotherapy (OR: 0.96; 95% CI, 0.94-0.99), and early occupational therapy (OR: 0.96; 95% CI, 0.93-0.98) than Danish-born residents. Small absolute differences in overall quality of stroke care were found when comparing immigrants and Danish-born residents. Significant factors associated with greater likelihood of stroke care included high income, high education, and cohabitation. Immigrants had lower chances of early stroke unit admission and received fewer individual early stroke care processes such as dysphagia screening, physiotherapy and occupational therapy than Danish-born residents. However, the absolute disparities were in general minor and largely influenced by socioeconomic status and cohabitation.

Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern Portugal

IntroductionPatients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH. Patients and methodsObservational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death. ResultsMortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816–40.241, p < 0.001), hospital arrival ≥ 6 h after stroke onset (OR = 2.842, 95% CI = 1.380–5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561–6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457–5.712, p =.002) and ≥ 24 h in the Emergency Department (OR = 19.675, 95% CI = 3.682–34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002). ConclusionThe observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.

Short- and long-term outcome and predictors in an international cohort of patients with neuro-COVID-19.

Background and purposeDespite the increasing number of reports on the spectrum of neurological manifestations of COVID‐19 (neuro‐COVID), few studies have assessed short‐ and long‐term outcome of the disease.MethodsThis is a cohort study enrolling adult patients with neuro‐COVID seen in neurological consultation. Data were collected prospectively or retrospectively in the European Academy of Neurology NEuro‐covid ReGistrY ((ENERGY). The outcome at discharge was measured using the modified Rankin Scale and defined as ‘stable/improved’ if the modified Rankin Scale score was equal to or lower than the pre‐morbid score, ‘worse’ if the score was higher than the pre‐morbid score. Status at 6 months was also recorded. Demographic and clinical variables were assessed as predictors of outcome at discharge and 6 months.ResultsFrom July 2020 to March 2021, 971 patients from 19 countries were included. 810 (83.4%) were hospitalized. 432 (53.3%) were discharged with worse functional status. Older age, stupor/coma, stroke and intensive care unit (ICU) admission were predictors of worse outcome at discharge. 132 (16.3%) died in hospital. Older age, cancer, cardiovascular complications, refractory shock, stupor/coma and ICU admission were associated with death. 262 were followed for 6 months. Acute stroke or ataxia, ICU admission and degree of functional impairment at discharge were predictors of worse outcome. 65/221 hospitalized patients (29.4%) and 10/32 non‐hospitalized patients (24.4%) experienced persisting neurological symptoms/signs. 10/262 patients (3.8%) developed new neurological complaints during the 6 months of follow‐up.ConclusionsNeuro‐COVID is a severe disease associated with worse functional status at discharge, particularly in older subjects and those with comorbidities and acute complications of infection.

Effects of delay to stroke unit admission in patients with ischemic and hemorrhagic stroke.

To determine the association between delay in transfer to a central stroke unit from peripheral institutions and outcomes. We conducted a retrospective cohort study of all patients with acute stroke, admitted to a comprehensive stroke center (CSC) from three emergency departments (EDs), between 2016 and 2018. The primary outcomes were length of stay, functional status at 3 months, discharge destination, and time to stroke investigations. One thousand four hundred thirty-five patients were included, with a mean age of 72.9 years, and 92.4% ischemic stroke; 663 (46.2%) patients were female. Each additional day of delay was associated with 2.0 days of increase in length of stay (95% confidence interval [CI] 0.8-3.2, p = 0.001), 11.5 h of delay to vascular imaging (95% CI 9.6-13.4, p < 0.0001), 24.2 h of delay to Holter monitoring (95% CI 7.9-40.6, p = 0.004), and reduced odds of nondisabled functional status at 3 months (odds ratio 0.98, 95% CI 0.96-1.00, p = 0.01). Factors affecting delay included stroke onset within 6 h of ED arrival (605.9 min decrease in delay, 95% CI 407.9-803.9, p < 0.0001), delay to brain imaging (59.4 min increase in delay for each additional hour, 95% CI 48.0-71.4, p < 0.0001), admission from an alternative service (3918.7 min increase in delay, 95% CI 3621.2-4079.9, p < 0.0001), and transfer from a primary stroke center (PSC; 740.2 min increase in delay, 95% CI 456.2-1019.9, p < 0.0001). Delay to stroke unit admission in a system involving transfer from PSCs to a CSC was associated with longer hospital stay and poorer functional outcomes.

POSA72 Cost-Effectiveness Analysis of the Helicopter Emergency Medical Services for Stroke Patients in Austria

Many patients suffer from acute stroke at a significant distance from dedicated stroke centers. Since onset of advanced stroke care is time critical, the impact of rapid transport provided by helicopter emergency medical services (HEMS) on patient outcome merits further evaluation. Accordingly, the aim of this study was to evaluate the cost-effectiveness of a HEMS compared with ground-based ambulance-transport for patients with acute stroke to a stroke unit (SU). A Markov-model was developed based on the modified Ranking Scale (mRS) states 90 days after stroke to simulate consequences over a 10-year time-horizon. Consequences include recurrent stroke, deteriorated mRS, death due to recurrent stroke or other reasons. Health benefits were measured in quality-adjusted life-years (QALYs) and life-years (LYs). Probabilities were derived from the literature mainly the stroke registry. According to data derived from the OEAMTC Air Rescue, 4.9% of all SU admissions are carried out by HEMS. The target value for an appropriate use of HEMS was assumed to be 20%. The assumption was because 18% of all patients admitted to a SU suffer a severe stroke (NIH-SS<13). Direct-costs (2020€) were derived from published sources from the payer’s perspective. QALYs, LYs and costs were discounted. Monte-Carlo-simulation accounted for uncertainty. A >20% proportion of stroke patients who were transported by HEMS to a SU is associated with savings over a 10-year time-horizon (3,500.- € to 10,191.- € per patient). Savings are due to a better neurological status (mRS after 90 days), because of the faster onset of stroke interventions. Patients also achieved a higher life expectancy (0.7 to 1.39 LYs) and quality of life [0.23 to 0.86 QALYs). In the entire cohort of stroke patients in 2020 (n=12,953), savings of 45.3 million euros could be achieved. 1€ spend in HEMS results in savings of 15.9.- € in the health-care and social system.

247 BENCHMARKING STROKE SERVICES TO INFORM A QUALITY IMPROVEMENT INIAITIVE

Abstract Background Stroke is a leading cause of death and disability in Ireland. Continuous audit and quality improvement is essential in the delivery of stroke care where the evidence basis is constantly changing. This helps to ensure the delivery of high quality stroke care and compliance with evidenced based guidelines. We aimed to assess stroke care at an Irish university teaching hospital. Methods Patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1st January-31st December 2019) were identified through both the HIPE database and the institutional Stroke Portal. Data was benchmarked against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice and used to inform a quality improvement strategy. Results 419 patients were included (56.6% male, median 57 years). 75.9% were aged 65 years or older. We compared favourably with Irish National Audit of Stoke national indicators on the following: thrombolysis rates-10%; median door to needle time-60 mins; stroke unit admissions- 78.5%; median duration of symptoms- 3 hours 6 minutes; swallow assessment- 81.1%; in-patient mortality- 10.5%; rates of institutionalisation- 3.8%. Areas identified for improvement were: thrombectomy rates- 1.9%; median length of stay- 12 days; door to imaging time- median 104 minutes; mood screening- 11.5%. Conclusion International and national data is a useful benchmark against which local hospitals can assess the quality of their service. By completing this quality improvement initiative we identified areas to target resources in our centre, including mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging. An ongoing quality improvement process using ‘PDSA’ methodology is being carried out with an annual audit to monitor progress.

Stroke Mimics on the Stroke Unit - Temporal trends 2008-2017 at a large Norwegian university hospital.

The objective was to quantify temporal trends in stroke mimics (SM) admissions relative to cerebrovascular accidents (CVA), incidence of hospitalized SMs and characterize the SM case-mix at a general hospital's stroke unit (SU). All SU admissions (n=11240) of patients aged 15 or older to Haukeland University Hospital between 2008-2017 were prospectively included and categorized as CVA or SM. Logistic regression was used to estimate time trends in the proportion of SMs among the admissions. Poisson regression was used to estimate time trends in age- and sex-dependent SM incidence. SMs were on average younger thaan CVA patients (68.3 vs. 71.4years) and had a higher proportion of females (53.6% vs. 44.5%). The total proportion of SM admissions was 51.0%. There was an increasing time trend in the proportion of SM admissions, odds ratio 1.150 per year (p<0.001), but this trend appears flattening, represented by a significant quadratic time-term, odds ratio 1.009 (p<0.001). A higher SM proportion was also associated with the time period of a Mass Media Intervention (FAST campaign) in 2014. There was also an increasing trend in SM incidence, that remains after adjusting for age, sex, and population; also, for incidence the trend appears to be flattening. SMs account for approximately half of the SU admissions, and the proportion has been increasing. A FAST campaign appears to have temporarily increased the SM proportion. The age- and sex-dependent incidence of SM has been increasing but appears to flatten out.

Central Triage of Acute Stroke Patients Across a Distributive Stroke Network Is Safe and Reduces Transfer Denials.

Mechanical thrombectomy has dramatically increased patient volumes transferred to comprehensive stroke centers (CSCs), resulting in transfer denials for patients who need higher level of care only available at a CSC. We hypothesized that a distributive stroke network (DSN), triaging low severity acute stroke patients to a primary stroke center (PSC) upon initial telestroke consultation, would safely reduce transfer denials, thereby providing additional volume to treat severe strokes at a CSC. In 2017, a DSN was implemented, in which mild stroke patients were centrally triaged, via telestroke consultation, to a PSC based upon a simple clinical severity algorithm, while higher acuity/severity strokes were triaged to the CSC. In an observational cohort study, data on acute ischemic stroke patients presenting to regional community hospitals were collected pre- versus post-DSN implementation. Safety outcomes and rate of CSC transfer denials were compared pre-DSN versus post-DSN. The pre-DSN cohort (n=150), triaged to the CSC, had a similar rate of symptomatic intracerebral hemorrhage and discharge location compared with the post-DSN cohort (n=150), triaged to the PSC. Time to stroke unit admission was faster post-DSN (2 hours 40 minutes) versus pre-DSN (3 hours 29 minutes; P<0.001). Transfer denials were reduced post-DSN (3.8%) versus pre-DSN (1.8%; P=0.02), despite an increase in telestroke consultation volume over the same period (median, 3 calls per day pre-DSN versus 5 calls per day post-DSN; P=0.001). No patients who were triaged to the PSC required subsequent transfer to the CSC. A DSN, triaging mild ischemic stroke patients from community hospitals to a PSC, safely reduced transfer denials to the CSC, allowing greater capacity at the CSC to treat higher acuity stroke patients.

Association Between Cemented vs Cementless Hemiarthroplasty and Short-Term Change of In-Hospital Mortality in Elderly Patients with Femoral Neck Fracture: A Propensity-Score Matching Analysis in a Multicenter Database

ObjectiveCemented hemiarthroplasty is recommended for the vulnerable hip fracture population because of beneficial long-term outcomes. However, the association between cemented hemiarthroplasty and short-term mortality is controversial. To increase a preparedness of potential complication after cemented hemiarthroplasty, we aimed to evaluate the trajectory of the effect of cemented hemiarthroplasty on short-term in-hospital outcomes.MethodsWe investigated in-hospital mortality and complications between cemented hemiarthroplasty and cementless hemiarthroplasty using a nationwide multicenter database from 2010 to 2016 with a propensity-score matching analysis. We analyzed in-hospital mortality from 1 to 14 days after surgery. We also investigated in-hospital complications that may associate with mortality.ResultsAfter matching of 31,322 cases, we found no significant difference in 30-day in-hospital mortality between the cemented and cementless hemiarthroplasty groups (hazard ratio, HR [95% confidence interval, CI], 1.2 [0.89–1.6], p = 0.23). However, the 1- to 10-day postoperative mortality rates were significantly higher in the cemented group and the association becomes weaker as the postoperative period increased (day 1; HR [95% CI]: 3.5 [1.6–7.68]; day 10; HR [95% CI]: 1.59 [1.07–2.37]). The incidence of stroke and intensive care unit (ICU) admission was also significantly higher in the cemented group.ConclusionCemented hemiarthroplasty was not significantly associated with an increase in overall in-hospital mortality but was significantly associated with short-term mortality from 1-day to 10-day after surgery. The incidence of stroke and ICU admission was also significantly higher in the cemented group. Surgeons should pay more attention to the risk of mortality and stroke in patients undergoing cemented hemiarthroplasty, especially in the early days of hospitalization.

Acute Stroke Care during the COVID-19 Pandemic: Reduction in the Number of Admissions of Elderly Patients and Increase in Prehospital Delays

Introduction: We analyzed whether the coronavirus disease 2019 (COVID-19) crisis affected acute stroke care in our center during the first 2 months of lockdown in Spain. Methods: This is a single-center, retrospective study. We collected demographic, clinical, and radiological data; time course; and treatment of patients meeting the stroke unit admission criteria from March 14 to May 14, 2020 (COVID-19 period group). Data were compared with the same period in 2019 (pre-COVID-19 period group). Results: 195 patients were analyzed; 83 in the COVID-19 period group, resulting in a 26% decline of acute strokes and transient ischemic attacks (TIAs) admitted to our center compared with the previous year (p = 0.038). Ten patients (12%) tested positive for PCR SARS-CoV-2. The proportion of patients aged 65 years and over was lower in the COVID-19 period group (53 vs. 68.8%, p = 0.025). During the pandemic period, analyzed patients were more frequently smokers (27.7 vs. 10.7%, p = 0.002) and had less frequently history of prior stroke (13.3 vs. 25%, p = 0.043) or atrial fibrillation (9.6 vs. 25%, p = 0.006). ASPECTS score was lower (9 [7–10] vs. 10 [8–10], p = 0.032), NIHSS score was slightly higher (5 [2–14] vs. 4 [2–8], p = 0.122), onset-to-door time was higher (304 [93–760] vs. 197 [91.25–645] min, p = 0.104), and a lower proportion arrived within 4.5 h from onset of symptoms (43.4 vs. 58%, p = 0.043) during the CO­VID-19 period. There were no differences between proportion of patients receiving recanalization treatment (intravenous thrombolysis and/or mechanical thrombectomy) and in-hospital delays. Conclusion: We observed a reduction in the number of acute strokes and TIAs admitted during the COVID-19 period. This drop affected especially elderly patients, and despite a delay in their arrival to the emergency department, the proportion of patients treated with recanalization therapies was preserved.

Pattern of Stroke and Short Term Outcome of COVID-19 Patients admitted in a Dedicated Stroke Unit at Referral Neurology Hospital of Bangladesh

Background: COVID-19 was declared as a pandemic by WHO on March 11, 2020. Though the most common and important presentation is with respiratory disease, reports of neurological features are increasing.&#x0D; Objective: In this study it was described the pattern of stroke in COVID-19 patients admitted in a dedicated stroke unit and their short term outcome.&#x0D; Methodology: This single arm, single centreprospective cohortstudy was conducted in the Stroke Unit of National Institute of Neurosciences and Hospital, Dhaka, Bangladesh from April to August, 2020 and wasincluded acute stroke patients irrespective of age and sex who were found RT-PCR positive for SARS CoV-2. The patientswere evaluated clinically, biochemically and by imaging. After diagnosis patients were referred to a COVIDdedicated hospital and were followed up over phone for 4 weeks from the day of admission in stroke unit to assess short term outcome.&#x0D; Results: Among the 41 patients, 21 were male and 20 female with an age range of 26 to 90 years where 58.5% patients were aged 60 and above. Majority (58.5%) of them came from different urban areas. Common co-morbidities were Hypertension (68.3%) and Diabetes mellitus (39%). Most common presenting features were hemiplegia (48.8%) and altered level of consciousness (39%). More than seventy percent (70.7%) patients had GCS of 10 or less and 56.1% patients had oxygen saturation 90% or less in room air. CT brain imaging revealed infarct in 39% and hemorrhage in 51.2%. Chest radiography revealed abnormality in 14.6% cases. Regarding the short term outcome, total 20 (48.8%) patients died where 7 died before referral to COVID-19 dedicated hospital. Death was higher in hemorrhagic stroke but there was no significant association between outcome and the type of stroke (p value&gt;0.05).&#x0D; Conclusions: Hemorrhagic stroke is the most commonly occurring stroke among the COVID-19 patients and associated with p oor outcome.&#x0D; Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 25-28

Simultaneous cardio-cerebral embolization. A prospective study

Abstract Background Atrial Fibrillation (AF) is a common cause of ischemic stroke but also the most common cause of Coronary Artery Embolism (CE). Many previous case of coexistence of coronary and cerebral embolism have been reported in the literature but in specific situations were clinical signs of stroke but also indisputable clinical and/or electrocardiographic (ECG) signs leaded to the realization of coronarography in emergency. Objectives The aim of the study was to determine the existence of simultaneous cardio-cerebral embolization associated in patients with ischemic embolic stroke on de novo AF, in the absence of clinical and/or ECG signs evocative of myocardial infarction (MI). Methods We prospectively included patients hospitalized in our institution for ischemic embolic stroke on de novo AF. Patients with history of ischemic disease were excluded. All patients had: 1/ troponin assay; 2/ Cardiac Magnetic Resonance (CMR) imaging with Late-Gadolinium Enhancement (LGE) in order to detect myocardial infarction; 3/ coronary exploration by cardiac CT scan or coronarography to exclude patients with significant coronary lesion. Results Between January and December 2019, 32 patients were included. Of them, 15 had subendocardial or transmural LGE on CMR, evocative of MI. Among these 15 MIs we classified acute MIs according to the level of troponin at the admission in stroke unit, the coronarography and T2 hypersignal on cardiac MRI. Median delay of cardiac MRI was 6 days for acute MIs. CE was clearly identified by coronarography for 4 patients with acute simultaneous cardio-cerebral infarction (56%). The MRI abnormalities showed that lesions of all MIs were transmural, relatively small (average 1.3±0.44 segments) and in most cases in the inferior cardiac wall (47%) and these abnormalities were comparable in sequelae and acute MI. Moreover, the left appendage morphology was a “cactus” in 62.7% of simultaneous acute cardio-cerebral infarction and only 33% in patients without MI or sequelae MI. Strokes were mainly localized in the superficial territory of the middle cerebral artery, and were similar in patients with or without MI. In addition, the rate of sequelae strokes was higher in isolated stroke group than “cardiocerebral infarction” (29.5% versus 13.3%). Conclusion Simultaneous acute cardio-cerebral infarction is not uncommon, diagnosed in 22% of our prospective cohort of embolic stroke. Cardiac MRI may help us to diagnose a concomitant cardiac embolization and evaluate the prognosis. Unfortunately optimal therapeutic strategy of these patients is still unknown. Flow Chart Funding Acknowledgement Type of funding source: None