In-hospital ischaemic stroke treated with intravenous thrombolysis or mechanical thrombectomy

Abstract

Patients with in-hospital strokes (IHS) may be eligible for recanalization therapies. The objective of this study is to compare outcomes in patients with IHS and community-onset strokes (COS) treated by recanalization therapy. We analysed data prospectively collected in consecutive patients treated by thrombolysis, thrombectomy, or both for cerebral ischemia at the Lille University Hospital. We compared four outcomes measures at 3 months in patients with IHS and COS: (1) modified Rankin scale (mRS) 0-1, (2) mRS 0-2, (3) death, and (4) symptomatic intracranial haemorrhage (ECASS 2 definition). Of 1209 patients, 64 (5.3%) had IHS, with an increasing proportion over time (p = 0.001). Their median onset-to-needle time was 128 min vs. 145 in COS (p < 0.001). They were more likely to have had a recent TIA [odds ratio (OR) 30.1; 95% confidence interval (CI) 11.5-78.7], to have been treated by vitamin K antagonist before (OR 4.2; 95% CI 1.4-12.0) and to undergo mechanical thrombectomy (45 vs. 10%, p < 0.001). They were less likely to have a pre-stroke mRS 0-1 (OR 0.22; 95% CI 0.09-0.50). After adjustment, IHS was not associated with any of the four outcome measures. Patients with IHS are treated 17 min earlier than patients with COS, but, taking into account that they were already in the hospital, delays are still too long. Their outcome does not differ from that of patients with COS, suggesting room for improvement if delays can be reduced. IHS being frequent, pre-specified pathways should be organised.

Intravenous thrombolysis for patients with in‐hospital stroke onset: propensity‐matched analysis from the Safe Implementation of Treatments in Stroke‐East registry

“…Given that there is a clear benefit of endovascular reperfusion therapies in patients with AIS with emergent large‐vessel occlusions, either with or without pre‐treatment with systemic thrombolysis , there is also an urge to increase in‐hospital awareness regarding endovascular reperfusion therapies as highly relevant treatment options in the setting of emergent large‐vessel occlusion and especially for patients with IHS who, due to prevalent comorbidities, might be ineligible for IVT. Notably, a recent French study reported markedly high mechanical thrombectomy treatment rates (45%) in a series of 64 patients with IHS .…”

Comparison between in-hospital stroke and community-onset stroke treated with endovascular thrombectomy

“…However, these findings might be somehow misleading because not all patients with IHS were candidates for acute intervention. When only patients who had received acute intervention were considered, one study found an even faster onset to intravenous thrombolysis time among patients with IHS than among those with COS (128 vs 145 min, P < 0.001) [21]. Another study also demonstrated an improvement in assessment and treatment time after an IHS alert protocol was established in a single hospital [22].…”

Improving care for acute in-hospital ischemic strokes—A narrative review

“…4 In-hospital stroke patients are also less likely to ambulate at discharge and more likely to have higher modified Rankin scores. 2,6 Similarly, lengths of stay are higher for in-hospital strokes. Mean length of stay after community-onset stroke is 13 days compared with 21 days after in-hospital strokes.…”

“…Aside from recurrent strokes on stroke units, cardiology and cardiac surgery units are the most common locations for in-hospital strokes to occur. 6,7,9 Not surprisingly then, in-hospital stroke mechanism is more often embolic (cardioembolic or arteroembolic). 3 In a Canadian provincial prospective cohort study, almost half of in-hospital strokes occurred during admission for surgery and 15% of strokes occurred during angiography.…”

“…4 In-hospital stroke patients are also less likely to ambulate at discharge and more likely to have higher modified Rankin scores. 2,6…”