outcomes

Burton J. Tabaac, MD
@burtontabaac

Diegoli H, Magalhães PSC, Martins SCO, Moro CHC, França PHC, Safanelli J, Nagel, V, Venancio VG, Liberato RB, Longo AL. Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era. Stroke. 2020.

On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic. As of this writing, the global number of cases exceeds 8.1 million. However, despite the rapidly increasing prevalence of COVID-19, many questions remain regarding this unusual and highly lethal disease. The pathogenesis of COVID-19–associated neurologic injury remains to be established. SARS-CoV-2 has been shown to induce a hypercoagulable state, thus increasing the risk of arterial thrombosis with acute ischemic stroke.(1)

From late 2019 to early 2020, COVID-19 started to disrupt the healthcare systems of many nations. From the beginning of the pandemic, it has been a major concern for doctors and public authorities that resources needed to treat other conditions such as stroke are diverted for COVID-19.(2) The authors are keen to note that “patients may be unwilling to go to a hospital for stroke treatment due to fear of becoming contaminated with the disease.” Using a population-based stroke registry, the authors of this original contribution investigated the impact of the onset of the COVID-19 pandemic on stroke admissions in Joinville, Brazil. The authors’ hypotheses were as follows: First, hospital admissions for stroke were reduced after the onset of the COVID-19 pandemic. Next, the reduction occurred only in transient ischemic attacks (TIA) and mild cases. Also, there was a change in the time between stroke onset and hospital admissions. Finally, the number of patients receiving reperfusion therapies (IVT and MT) has decreased.

Elena Zapata-Arriaza, MD
@ElenaZaps

Boehme AK, Kulick ER, Canning M, Alvord T, Khaksari B, Omran S, et al. Infections Increase the Risk of 30-Day Readmissions Among Stroke Survivors: Analysis of the National Readmission Database. Stroke. 2018;49:2999–3005.

Infection is a most frequent medical complication after stroke. It is well recognized that acute stroke induces both the central nervous system and peripheral inflammatory responses, and, infection during stroke admission increases acute and longer-term inflammatory responses, complicating stroke outcomes. However, up to now, clinical trials with prophylactic aim in infection after stroke have failed. Therefore, stroke and infection develop a negative feedback between them.

Based on the known association between infection and stroke outcomes, the authors performed a weighted analysis of the federally managed 2013 National Readmission Database to assess the relationship between infection during a stroke hospitalization and 30-day readmission (30dRA) among ischemic stroke survivors. The main goal of this paper was to confirm the relation between stroke infection and 30dRA. The novelty of the paper is the identification of stroke associated infection as a predictor of readmission, not only as the most frequent cause of a new hospitalization. The authors employed the International Classification of Disease Ninth Revision [ICD-9] codes to identify ischemic stroke patients with ICD-9 codes present in the first diagnostic position ischemic stroke (referred as primary ischemic stroke patients) and patients with ischemic stroke code at any diagnostic position (referred as all ischemic stroke patients). The primary outcome, 30dRA, was classified as any hospitalization occurring within the 30-day postdischarge window and classified into planned or unplanned readmissions using previously validated ICD-9 codes. Secondary outcomes, 7dRA and 60dRA, were also assessed and were classified as any hospitalization occurring within the 7 days, or 60 days, postdischarge window.

Kevin S. Attenhofer, MD

Dijkland SA, Voormolen DC, Venema E, Roozenbeek B, Polinder S, Haagsma JA, et al. Utility-Weighted Modified Rankin Scale as Primary Outcome in Stroke Trials: A Simulation Study. Stroke. 2018

As stroke neurologists, we are all intimately familiar with the modified Rankin Scale (mRS) as a measure of degree of disability. It is a common outcome measure in stroke research and can be statistically analyzed as a simple dichotomization or ordinal shift (among other options). The dichotomized outcome takes varied and complex neurological outcomes and simplifies them down to nominal variables of “good” or “bad.” This is statistically more straightforward, but does result in some outcome information being discarded. The ordinal shift retains more of this information, but typically requires larger sample size to maintain adequate power. Even when well powered, however, the mRS still has a disproportionate focus on motor function when compared to other neurological domains, such as cognition or patient metrics such as quality of life.

Neal S. Parikh, MD 
@NealSParikhMD

Dozois A, Hampton L, Kingston CW, Lambert G, Porcelli TJ, Sorenson D, et al. PLUMBER Study (Prevalence of Large Vessel Occlusion Strokes in Mecklenburg County Emergency Response). Stroke. 2017

Optimizing access to endovascular therapy has become a public health priority. While various national guidelines seek to shape acute stroke EMS triage practices broadly, regulatory bodies have also acknowledged the need to tailor protocols to local and regional environments.

In deciding whether to triage an individual patient with suspected stroke to an endovascular center instead of a primary stroke center, EMS may consider factors such as relative travel distances, stroke severity, and the likelihood of a large vessel occlusion (LVO).

LVO screening tools have inherent imprecision, and the positive predictive value, of course, depends on the prevalence of LVO. For this reason, knowing the prevalence of LVO among acute ischemic stroke 9-1-1 dispatches is of importance. Further, at an organizational level, the accuracy and precision of LVO detection in the field has upstream implications for case load at endovascular and non-endovascular centers. The importance of these considerations varies by locale.