outcomes

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.

Abbas Kharal, MD, MPH, and Richa Sharma, MD, MPH

Jagolino-Cole AL, Bozorgui S, Ankrom CM, Bambhroliya AB, Cossey TD, Trevino AD, et al. Benchmarking Telestroke Proficiency: Page-to-Needle Time Among Neurovascular Fellows and Attendings. Stroke. 2017

Telestroke management is built into the curriculum of many vascular neurology fellowships and affords fellows (NVF) the opportunity to achieve proficiency in this modality. This study demonstrates that the page-to-needle time, or PTNT, is higher among NVFs compared to NVAs. As a result, the authors are suggesting that PTNT is a metric of proficiency. Given lower PTNT among NVAs compared to NVFs, there is an assumption that further training may decrease PTNT and, transitively, increase proficiency. As such, there may be a benefit in greater emphasis of dedicated telestroke training during fellowship.

There is an inherent truth in the logic that additional training can result in decreased PTNT just by sheer procedural repetition to learn the logistics of data-gathering by the phone, video, and imaging from an outside institution. However, perhaps the process is also faster for NVAs compared to fellows due to the attendings’ greater body of experiences seeing numerous patients with each stroke syndrome, treating them acutely, and then following the clinical course in the rehabilitation and subacute phase. Thus, proximal care of stroke patients longitudinally may aide in faster decision-making for remote, telestroke patients. Given that most vascular neurology fellowships are only one clinical year, it is thus critical that telestroke training does not supersede rotations, which require direct patient contact throughout the spectrum of the disease, since it is this contact which informs the decision-making process in the practice of telestroke.