American Heart Association

Yearly Archives: 2016

Results of the Japanese Primary Prevention Project

Neal S. Parikh, MD

In Stroke, Dr. Uchiyama and colleagues report on their investigation of aspirin for primary stroke prevention in an at-risk, elderly cohort in Japan.

The Japanese Primary Prevention Project was intended to investigate the utility of aspirin for primary prevention in an Asian population–a population thought to be at greater baseline risk of intracranial hemorrhage (ICH). In this paper, the authors present results of a post-hoc analysis regarding ischemic stroke, TIA and ICH.

The study was a nationwide, multicenter, randomized, open-label trial. Patients between the ages of 60-85 and with at least one vascular risk factor were recruited from 2005 to 2007 by primary care doctors. Patients with a prior vascular event and those with atrial fibrillation were excluded, as were those with bleeding disorders and those already on a different anti-platelet agent. Patients were randomized to 100 mg of aspirin or no aspirin.

The primary outcome was a composite of cardiovascular death, nonfatal stroke, and nonfatal MI. Ischemic stroke, ICH, TIA were among the secondary endpoints, of which ischemic stroke, TIA, and ICH are specifically discussed in this article.

Over 14,000 patients were followed for median of 5 years. The mean age was 70, and approximately 60% of patients were female. 85% of patients in both groups had hypertension, 72% had dyslipidemia, and 34% had diabetes. Self-reported adherence in the aspirin group at 5 years was 76%; adherence to the no aspirin assignment was 90%.

At 5 years, there was not a significant difference in the cumulative rate of any stroke or TIA: 2.068% in the aspirin group versus 2.299% in the no aspirin group; adjusted HR 0.927 (95% CI, 0.74-1.16). Similarly, there was not a significant difference in the individual outcomes of any stroke, ischemic stroke, and ICH. In Cox regression analysis, aspirin use was not significantly associated with cerebrovascular outcome rates.

The results are consistent with prior studies conducted in Western populations in which aspirin was not effective for stroke primary prevention. The key take home message may be the explanation of low outcome rates: aggressive risk factor management, particularly of hypertension.
By |June 7th, 2016|treatment|Comments Off on Results of the Japanese Primary Prevention Project

Cortical Neuronal Damage in Atherosclerotic Large Artery Disease

Russell Mitesh Cerejo, MD

Yamauchi H, Kagawa S, Kishibe Y, Takahashi M, Higashi T. Progressive Cortical Neuronal Damage and Chronic Hemodynamic Impairment in Atherosclerotic Major Cerebral Artery Disease. Stroke. 2016

In their paper, the authors set out to determine whether selective cortical neuronal damage manifests as a decrease in BZRs in the normal appearing cerebral cortex of patients with atherosclerotic ICA or MCA occlusive disease, and furthermore whether these changes can be correlated with chronic hemodynamic impairment at baseline or hemodynamic deterioration. They studied 80 patients with atherosclerotic ICA or MCA disease with 17 having TIAs, and 38 having completed stroke.

The authors found that the BZR index in 40 patients was increased during follow-up (mean 26±20 months). In multivariable logistic regression analyses, increases in the BZR index were associated with the decreased cerebral blood flow at baseline and an increased oxygen extraction fraction during follow-up. They hypothesize that misery perfusion at baseline is associated with subsequent development of ischemic cortical neuronal damage. The contribution of the increased BZR index at baseline suggests that patients with misery perfusion have already suffered some ischemic cortical neuronal damage and may be at particular risk for progressive cortical neuronal damage.
They also found that increases in the oxygen extraction fraction during follow-up were associated with a lack of statin use. They suggest that revascularization procedures can improve hemodynamic impairment and thus may be beneficial to patients vulnerable to selective neuronal damage. 

By |June 6th, 2016|pathogenesis|Comments Off on Cortical Neuronal Damage in Atherosclerotic Large Artery Disease

Bone Marrow Derived Mononuclear Cells Improve Functional Outcomes in Animal Models of Ischemic Stroke

Mark R. Etherton, MD, PhD

Despite the advent of efficacious treatments for acute ischemic stroke, in the form of intravenous tPA and endovascular thrombectomy, post stroke disability is frequent. The prevalence of post stroke disability has served as the impetus for significant research into modalities to augment post stroke recovery. One promising approach is cellular therapy; including bone marrow derived mono-nuclear cells (BMMNCs), which have shown beneficial effects in animal models of ischemic stroke.

In this study, the authors conducted a systematic review of manuscripts using intravenous BMMNCs in animal models of ischemic stroke and performed a meta-analysis of histological and behavioral outcomes. They identified 22 studies in which the majority had assessments of common variables pertaining to infarct size and motor/functional outcomes.
While there was obvious heterogeneity among the individual studies with regards to methodologies and outcomes assessed. The pooled analysis was possible, in part, because the authors identified important shared approaches in the selection of specific animal models, timing of BMMNC injection, and outcome variables assessed (e.g. reduction in infarct size, cylinder test). BMMNC treated animals had significantly reduced infarct size (standardized mean difference -3.3, 95% CI: -4.3, -2.3) and enhanced performance on tests of sensorimotor function (cylinder test SMD -2.4, 95%CI: -3.1, -1.6).

This meta-analysis serves as an important summary of the pre-clinical data for one subtype of cellular therapy in ischemic stroke. BMMNCs have beneficial effects on infarct size and behavioral outcomes in animal models of ischemic stroke. Ideally, this study will serve as a platform on which future studies can build to target clinical trials for cellular therapies in human post stroke recovery.

By |June 3rd, 2016|basic sciences|Comments Off on Bone Marrow Derived Mononuclear Cells Improve Functional Outcomes in Animal Models of Ischemic Stroke

High BP at time of Stroke Associated with Increased Risk of Recurrent Stroke in the Young

Alexander E. Merkler, MD

Mustanoja S, Putaala J, Gordin D, Tulkki L, Aarnio K, Pirinen J, et al. Acute-Phase Blood Pressure Levels Correlate With a High Risk of Recurrent Strokes in Young-Onset Ischemic Stroke. Stroke. 2016

Hypertension is one of the most important stroke risk factors and one in four adults has hypertension. Lowering blood pressure is associated with a decreased risk of cardiovascular mortality and recurrent strokes in the elderly. Although risk factors for stroke in the young are different, the prevalence of hypertension in young adults has already doubled in the past two decades, making it a significant risk factor for cardiovascular mortality even in young patients. In this study, Dr Mustanoja et al. evaluate whether acute blood pressure recordings during an ischemic stroke are associated with recurrent stroke.

The authors performed a retrospective single-center study of 1004 patients with acute ischemic stroke <50 years of age. Of these patients, 39% had pre-stroke hypertension and 36% used antihypertensive treatment. Over a median follow-up period of 8.9 years, 14% suffered a recurrent stroke (including ischemic and hemorrhagic). Patients with recurrent stroke had a significantly higher admission SBP, DBP, pulse pressure (PP), and mean arterial pressure (MAP) than patients without recurrent stroke. Using a cox proportional hazards model, having a SBP³160mmHg was significantly associated with a higher risk of recurrent stroke (Hazard ratio 3.3 (95% CI, 2.1-4.6) as compared to patients with an admission SBP<160mmHg. In addition, those patients with an admission SBP160mmHg were more likely to have a recurrent event earlier those patients with a SBP<160mmHg (at 13.9 versus 16.2 years). Similar findings were seen for DBP³100mmHg.

Certain limitations apply; for example, although the authors state that the their findings were unchanged irrespective of whether patients used anti-hypertensive treatment post-stroke, it’s unclear which agent, the duration of the agent, and most importantly, the efficacy of the agent. In addition, the findings may not be entirely generalizable as the study was conducted on only Caucasians at a single center in Scandanavia.

Despite these limitations, the results emphasize the importance of hypertension in stroke in the young and the necessity to aggressively control elevated blood pressure in adults of any age.

By |June 2nd, 2016|clinical|Comments Off on High BP at time of Stroke Associated with Increased Risk of Recurrent Stroke in the Young

Perfusion MRI in Perinatal Stroke

Russell Mitesh Cerejo, MD

Watson CG, Dehaes M, Gagoski BA, Grant PE, Rivkin MJ. Arterial Spin Labeling Perfusion Magnetic Resonance Imaging Performed in Acute Perinatal Stroke Reveals Hyperperfusion Associated With Ischemic Injury. Stroke. 2016

In their paper, the authors described a novel method to assess perfusion in perinatal strokes in the ischemic as well as penumbra tissue. 
They included subjects less than 28 days old at time of diagnosis, and included both arterial and venous infarcts. MRI was carried out on 3T scanners with arterial spin labeling (ASL) techniques used for non-contrast perfusion imaging. Out of 25 neonates that participated, 16 were males (64%). Median gestational age at birth was 38.7 weeks (range: 35.7-41.9), median (estimated) age at stroke was 1 day (i.e., second day of life) (range: 0-8), and median age at MRI was 3 days (range: 0-16). The median time from symptom onset to MRI acquisition was 2 days (range: 0-8).

Arterial ischemic stroke was present in 11 (44%), while venous infarction was found in 9 (36%). Five patients (20%) had both arterial and venous stroke. Hyperperfusion was seen in 73% of arterial ischemic strokes, 11% with venous stroke, and 80% with both. Hypoperfusion was observed in 33% with venous and none with arterial stroke. Perfusion was normal in 45% with venous and 20% with both. In nearly all patients presenting with clinical or electrographic seizures, EEG abnormalities were present in the same hemisphere as the stroke; this clinical feature did not differ by stroke type.

This study demonstrates that perfusion imaging can be obtained in neonates with acute stroke, and often reveals hyperperfusion in the infarct core. Penumbra in arterial infarcts is seldom found. Hyperperfusion may be due to post-stroke reperfusion or to neuronal hyperexcitability of stroke-associated seizure.
By |June 1st, 2016|diagnosis and imaging|Comments Off on Perfusion MRI in Perinatal Stroke

FLAIR Vascular Hyperintensities in Bordezone Strokes

Allison E. Arch, MD

Kim and colleagues investigated the clinical significance of FLAIR vascular hyperintensities in watershed strokes, and they tried to predict poor prognosis using these FLAIR changes as a marker of impaired hemodynamics.

Watershed, or borderzone, strokes represent 10% of all ischemic infarcts. The authors of this study defined 2 types of borderzone strokes: internal borderzone infarcts (IBZ), which are lesions between the deep and superficial perforating arterial territories of the MCA, and cortical borderzone infarcts (CBZ), which are between the MCA/ACA or the MCA/PCA territories. A patient was then considered FLAIR-positive he had 2 or more FLAIR vascular hyperintensities in his MCA territory on MRI, which were thought to have occurred prior to the stroke.

Eighty-seven consecutive patients with acute borderzone strokes were identified, 62 with CBZ and 55 with IBZ. Thirty of all included stroke patients were considered FLAIR-positive. The authors found that FLAIR vascular hyperintensities were associated with a more severe clinical presentation and a poorer clinical prognosis in patients with CBZ strokes, but not in patients with IBZ strokes. They concluded the presence of FLAIR vascular hyperintensities, “may help to identify CBZ-infarcted patients who require close observation and hemodynamic control.”
Their findings are interesting. The authors noted that the presumed pathogenesis of watershed strokes is microembolization in combination with hemodynamic disturbance. However, in patients with FLAIR vascular hyperintensities on MRI, there may be an additional hemodynamic-compromised insult during the stroke, which then leads to poorer outcomes. Kim and colleagues pointed out that in the CBZ group, those who had FLAIR vascular hyperintensities had similar sized DWI lesions to those patients who did not have FLAIR lesions. However, there were significant perfusion differences between the FLAIR-positive and FLAIR-negative groups, lending support to the concept that FLAIR vascular hyperintensities on MRI may signify that the patient is more influenced by hemodynamic instability than his FLAIR-negative counterpart.

It is unclear why this would be on the case in CBZ strokes but not in IBZ strokes. Further investigations are needed to help elucidate the importance of hemodynamics in borderzone strokes. 
By |May 31st, 2016|diagnosis and imaging|Comments Off on FLAIR Vascular Hyperintensities in Bordezone Strokes

Clinical Implications and Determinants of Left Atrial Mechanical Dysfunction in Patients with Stroke

Peggy Nguyen, MD

Kim D, Shim CY, Hong G-R, Kim M-H, Seo J, Cho IJ, et al. Clinical Implications and Determinants of Left Atrial Mechanical Dysfunction in Patients With Stroke. Stroke. 2016

Cardiovascular evaluation is an important part of the evaluation of the stroke patient, in part due to its use to diagnose cardioembolic etiologies of stroke, but also to assess for risk of future events. Left atrial enlargement has been associated with recurrent and first episodes of stroke, even in cases where dysrhythmias are not present; however, the mechanism by which this occurs is not well understood. Here, the authors use TTE with speckle tracking imaging to (1) assess enlargement and impaired mechanical function of the left atrium to define the risk of cardioembolism in stroke patients and (2) define the major determinants of left atrial mechanical dysfunction in these patients.

Two hundred forty-eight patients, derived from a larger study population of 316 acute ischemic stroke patients, who were referred for TTE and TEE, were analyzed. All patients underwent routine TTE, a TEE, as well as 2D speckle tracking echocardiography of the left atrium. Left atrial function was defined by the global left atrial longitudinal strain (LALS) and patients were divided into four groups for analyses: Group 1 – small LA with preserved LALS, Group 2 – large LA with preserved LALS, Group 3 – small LA with impaired LALS, and Group 4 – large LA with impaired LALS. Patients with large LA but impaired function (LALS) were significantly older than the other groups and experienced higher frequency of embolic strokes. 

The authors delve deep into the relationship between echo parameters of LA size and function. A global LALS less than 11.5% was found to be more predictive of a LA or LA appendage thrombus than LA volume index. Both global LALS and LA volume index were predictive of parameters which are suggestive of thrombus formation (and therefore, cardioembolic stroke risk), such as decreased LAA emptying velocity < 20 cm/s and complex aortic plaque. Left atrial function is independently correlated with age, LV function, LA volume index, and aortic stiffness.

The global LALS assessed using 2D speckle tracking imaging on TTE, being predictive of parameters suggestive of thrombus formation and being predictive of thrombus itself, provides an additional measurement which we can use to stratify patients, which can be of particular utility for patients who cannot tolerate a TEE. The presence of impaired global LALS may not be sufficient in of itself to warrant anticoagulation without further investigation, but it should prompt further studies, either the more invasive TEE or cardiac CT or MRI, which is not as widely available. 
By |May 24th, 2016|clinical|Comments Off on Clinical Implications and Determinants of Left Atrial Mechanical Dysfunction in Patients with Stroke

Validating Functional Outcome Prediction Models in Acute Ischemic Stroke: Testing the ASTRAL and DRAGON Scores

Danny R. Rose, Jr., MD

Cooray C, Mazya M, Bottai M, Dorado L, Skoda O, Toni D, et al. External Validation of the ASTRAL and DRAGON Scores for Prediction of Functional Outcome in Stroke. Stroke. 2016

Given that functional outcome is one of the most commonly used parameters in studying acute stroke treatment, developing accurate prognostication scores would greatly facilitate treatment decisions and improve communicating expectations to patients and families. Cooray et al. sought to validate the two most recently developed scores designed to predict functional outcome at three months, one studied in unselected acute stroke patients (ASTRAL) and the other in acute stroke patients treated with iv-tPA (DRAGON) using the SITS-International Stroke Thrombolysis Register (ISTR), a  global stroke thrombolysis database. Outcomes were dichotomized into modified Rankin Scale (mRS) 0-2 and 3-6 as were done in both of the initial studies, and the area under the curve (AUC) of the receiver operating characteristic (ROC) was used in both scores to assess the overall predictive and discriminative performance.

The ASTRAL score was developed in a single center stroke cohort using multivariate logistic regression analysis. It consists of 6 clinical parameters: age at stroke onset (1 point per 5 years), baseline National Institutes of Health Stroke Scale (NIHSS) score (1 point per NIHSS point), time from symptom onset to admission > 3 hours (2 points), any stroke-related visual field defect (2 points), acute blood glucose >7.3 or <3.7 mmol/L (1 point) and decreased level of consciousness based on item 1a on the NIHSS (3 points). A total of 36,131 iv-tPA treated patients with complete data for the ASTRAL score were registered in the SITS-ISTR database. The main differences between the SITS-ISTR and ASTRAL cohorts were higher mean baseline stroke severity (NIHSS 12 vs 9) and a lower proportion of functional independence at 3 months in SITS, which is likely explained by the higher severity. The AUC-RPC value for functionally dependent outcome (mRS 3-6) of the ASTRAL score using this cohort was 0.790 (95% CI 0.786-0.795). Over the rante of scores, the largest discrepancy between the observed and predicted outcome was found to be 11%.

The DRAGON score was developed in a single center cohort of acute ischemic stroke patients treated with iv-tPA using similar statistical design to the ASTRAL score. It is a 10 point scale and the included parameters are hyperdense cerebral artery sign (1 point) and early infarct signs (1 point) on baseline CT, pre-stroke mRS score >1 (1 point), age (<65 years = 0 points, 65-79 years = 1 point, >80 years ≥ 2 points), acute blood glucose >8 mmol/L (1 point), time from symptom onset to treatment >90 min (1 point) and NIHSS score (0-4 = 0 points, 5-9 = 1 point, 10-15 = 2 points and >15 = 3 points). A total of 33,716 iv-tPA treated patients with complete data for the DRAGON score were registered in the SITS-ISTR database. The main differences between the SITS and DRAGON cohorts were higher median baseline stroke severity (NIHSS 12 vs 9), lower proportion of early infarct signs (16.5% vs 30.6%) and higher onset-to-treatment time in the SITS cohort. The AUC-ROC value for functionally dependent outcome on the DRAGON score using the SITS-ISTR cohort was 0.77 (95% CI 0.769-0.779). The largest discrepancy between observed and predicted outcome was close to 17%.

Despite the limitations of using a retrospective analysis, the authors’ validation of the ASTRAL and DRAGON scores suggest an acceptable prognostic value for both. Despite being designed and validated using an unselected cohort that included thrombolysed and non-thrombolysed patients, the ASTRAL score showed a similar discriminative performance to the DRAGON score in this study. Future studies involving these scores would benefit from collecting data prospectively and including patients receiving endovascular therapy.
By |May 23rd, 2016|clinical|1 Comment

Predicting Large Vessel Occlusions in Ischemic Stroke Patients: Search for the Holy Scale

Ilana Spokoyny, MD
If a scale existed that could accurately predict the presence of large vessel occlusion (LVO), it would be extremely useful in triaging patients to either primary or comprehensive stroke centers (CSCs). For patients with LVO who are candidates for endovascular therapy, every minute is critical. Time lost by triaging these patients to primary stroke centers (PSCs) without endovascular capability is time and brain lost. Unfortunately, the range of stroke scales is wide and score cutoffs are inconsistent, and data on their predictive value for detecting LVO is limited. 

The authors of this study assessed 13 different clinical scales for their ability to predict LVO. The cutoff score for each scale which was associated with an under-10% false negative rate (FNR) was also calculated. The false negative rate would include patients with LVO who were not detected by the score cutoff, and so this number would ideally be minimal. Of over 1000 acute stroke patients seen from 2008-2015, about one-third had large artery occlusion (ICA, M1, or basilar). Patients transferred from a primary stroke center for endovascular therapy were excluded, as the authors mention this would have led to too high a prevalence of large vessel occlusions.

The scales included were: modified NIHSS (mNIHSS), 3-item stroke scale (3I-SS), Rapid Arterial oCclusion Evaluation Scale (RACE), Cincinnati Prehospital Stroke Scale (CPSS), Cincinnati Prehospital Stroke Severity Scale (CPSSS), Maria Prehospital Stroke Scale (MPSS), shortened versions of the NIHSS (sNIHSS-1, sNIHSS-5, sNIHSS-8), abbreviated NIHSS (aNIHSS), out-of hospital NIHSS (OoH-NIHSS), retrospective NIHSS profiles (rNIHSS: A to F), and Recognition of Stroke in the Emergency Room (ROSIER). The NIHSS was calculated for each patient on admission (median of 7), and the remaining stroke scale scores were retrospectively calculated from NIHSS score components. The published accepted cutoffs for each score were used to assess predictive value for LVO, and if there was not a published value, the cutoff which maximized the sum of specificity and sensitivity for LVO was used. 

The scores with the highest accuracy were NIHSS (11 and over) and RACE (5 and over), which had 79% accuracy, but these cutoffs were associated with false negative rates (FNR) around 30%. Using NIHSS >= 11 as a cutoff in this cohort would have led to sending 35% of the cohort to a CSC, but 27% of LVO patients would have been inappropriately triaged to primary stroke centers when they should have been sent to a CSC. This false negative rate of 27% falls in the published range for NIHSS >= 11, which has been reported between 12-35%. 

Arguably, it is worse to have a high FNR than a high FPR. A high FNR means time (and brain) lost, while a high FPR means overburdening the CSCs (but not necessarily worse care for patients). To achieve a FNR under 10%, the cutoff scores had to be quite low – the NIHSS cutoff was 5, mNIHSS was 3, RACE was 1, and Cincinnati Prehospital Stroke Severity Scale (CPSSS) was zero. As expected, using published cutoff scores (such as NIHSS 11) for triage would inappropriately send about 25% of patients with LVO to centers without endovascular capability. If, however, we used the calculated cutoffs which reduced the FNR to under 10% (such as NIHSS of 5), 60% of patients would have been sent to a comprehensive stroke center, 46% of whom would have been futile transfers, overburdening the system. 

Limitations noted by the authors include the changing cutoff score for LVO as time passes, the lower predictive value of NIHSS for LVO in the posterior circulation, and the lack of training of emergency medical teams in performing the NIHSS. The simpler scales seemed to be a solution to address the complexity of the NIHSS, but these scores posed similar problems in this analysis as did the NIHSS. This important study highlights the pitfalls of using the existing clinical scales to predict LVO. The authors recommend that intracranial artery imaging should be performed in all stroke patients presenting within 6 hours of onset, since the scores cannot be reliably used. They bring up the idea of a mobile stroke unit, which could be used to image in the field and triage patients. Additionally, biomarkers and TCDs have potential roles in the future for detecting LVO stroke patients in the field. This study is limited by its population, in that the patients were all admitted to a CSC and had a diagnosis of stroke. A study on the predictive value of stroke scales performed in the prehospital setting would provide real-world data along with the ability to quantify the role of the examiner’s proficiency with the stroke scale. In the meantime, optimizing the transfer process to swiftly identify and transport LVO patients from PSCs to a CSC with endovascular capability is critical to ensure that our patients get the best stroke care possible.

By |May 20th, 2016|clinical|Comments Off on Predicting Large Vessel Occlusions in Ischemic Stroke Patients: Search for the Holy Scale

Structured Nurse Practitioner Transitional Stroke Program Reduced 30-day Readmissions after Stroke

Qing Hao, MD, PhD

After discharge from hospital, strokes survivors usually are faced with physical and cognitive impairments, complex medication regimen, new diagnosis of other medical illness and need of social support which all significantly affect stroke recovery and readmissions due to stroke related complications or other medical conditions. The experience from non-stroke patients that addressed the cumulative complexity (patients’ demands and capacity) have demonstrated effective interventions for reducing 30-day readmissions, however, the transitional care models for stroke patients have not been well established. Condon and colleagues developed a model of Transitional Stroke Clinic (TSC) led by nurse practitioner(NP) and investigated its role in reducing readmissions by conducting an observational quality improvement study in a single academic, tertiary referral center.

Two phases of transitional care model were implemented from 10/2012 to 09/2015: 

Over 3 years, among 1421 stroke or TIA patient who were discharged home, 510 patient were enrolled into the transitional care model with a mean age of 65 and median NIHSS of 2. A lower TSC show rate was observed in patients readmitted within 30 days (60.8% vs 76.3% not readmitted; p=0.021); a similar trend was noticed in those readmitted within 90 days (67.5% vs 76.4%; p=0.088).
Multivariate analysis showed the TSC visits independently reduced the 30-day readmission by 48% (OR 0.518, 95% CI 0.272, 0.986; p=0.045), and the reduction was not significant for 90-day readmission. Prior stroke and multiple chronic conditions were associated with both 30-day and 90-day readmission.  Other factors that significantly affected 90-day readmission were prior hospitalization, and male gender.
Interestingly, compared with phase I, the phase II protocol made more follow-up phone calls earlier and were able to see all patient in TSC earlier using a structured clinic visit template (although the details of structured vs not structured were not specified), the rate of TSC visit and readmissions in 30 day and 90 day did not differ significantly in two phases.  This is probably because the readmission mainly occurred in high-risks patients, by focusing on this group of population, phase I protocol was able to effectively reduce the readmission rate. In addition, both phases followed the concept of cumulative complexity and spent significant effort on education, coordinating care with referral to therapy and community services, addressing social needs and handing off the care to the primary care which are also important interventions that enhanced patient care.  The phase I model that requires less time and resources may be preferred in future practices, but further investigations are needed. 
With a few limitations (e.g., not covering the patients who were discharged to rehab or skilled nursing facilities with higher NIHSS and who may be at higher risks of readmission, possibility of underestimation of readmission rate), this study showed promising result that early evaluation in NP-led structured transitional clinic was able to reduce readmission at 30 day by about 50% in stroke patients who were discharged home.  We are very glad that a pragmatic clinical trial based on these results is being implemented in North Carolina and we look forward to the standardized, effective and practical transitional care models for stroke survivors.
By |May 19th, 2016|outcomes|Comments Off on Structured Nurse Practitioner Transitional Stroke Program Reduced 30-day Readmissions after Stroke