Risk profile and treatment options of acute ischemic in-hospital stroke

Abstract

Despite the potential immediate access to diagnosis and care, in-hospital stroke (IHS) is associated with delay in diagnosis, lower rates of reperfusion treatment, and unfavorable outcome. Endovascular reperfusion therapy has shown promising results in recent trials for community-onset strokes (COS) and is limited by less contraindications than systemic thrombolysis. Thus, endovascular approaches may offer additional acute treatment options for IHS. We performed a retrospective, observational monocentric analysis of patients with acute ischemic stroke between January 2010 and December 2014. Out of 3506 acute ischemic strokes, 331 (9.4%) were IHS. In-hospital mortality (31.4 vs. 8.0%) and duration of stay after stroke (19.5 vs. 12.1 days) were higher in IHS than in COS. Most IHS occurred in cardiologic and cardiosurgical patients after catheterization or surgery. In 111 cases (33.5%) the time of onset could not be established as a result of sedation or delayed referral resulting in delayed symptom recognition. 52 IHS (15.7%) and 828 COS (26.0%, p < 0.001) patients received any kind of reperfusion therapy, of which 59.6% (IHS) and 12.1% (COS) comprised isolated endovascular interventions (p < 0.001). Intra-hospital delays (time to brain imaging, systemic thrombolysis, and angiography) were longer and outcome parameters (mRS d90, in-hospital mortality, length of stay) were worse in IHS, whereas rates of procedural complications and intracranial hemorrhages were similar in both groups. The overall rate of reperfusion treatment is lower in IHS compared to COS, as IHS patients are less likely to be eligible for systemic thrombolysis. Interventional stroke treatment is a safe and feasible therapeutic option for patients who are not eligible for systemic thrombolysis and should be anticipated whenever IHS is diagnosed.

In-hospital stroke

“…Most ischemic IHS occur on cardiological or cardiosurgical wards 11 after coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) 9,12 or, more generally, after invasive procedures (70%) 13 . Accordingly, most patients with IHS are hospitalized because of myocardial infarction (MI) or CABG 14 .…”

“…Stroke etiology according to TOAST criteria 15 is more often reported to be cardioembolic or undetermined in comparison to COS 12,14 . Inflammation, diabetes, dehydration, hypertension or instable blood-pressure, reduced renal function, reduced left ventricular ejection faction, newly detected atrial fibrillation and previous MI or stroke have been described as independent risk factors for IHS [16][17][18][19][20] .…”

“…Stroke after MI or CABG is a serious complication and increases in-hospital mortality significantly 24,25 . IHS patients are less likely to be discharged home (27.7% (IHS) vs 49.9% (COS)) or to be functionally independent (31.0% (IHS) vs 50.4% (COS)) 3 and remain hospitalized for a longer time (mean 19.5 (IHS) vs 12.1 days (COS)) 12 . They are more likely to experience incontinence, dysphagia, a lower level of consciousness and higher grade of motor deficit 26 .…”

“…The differences in the course of disease and outcome are foremost attributed to the underlying disease 5 , but also to the greater stroke severity 3 and possibly to a higher rate of large vessel occlusions (LVO) 12 ) as well as due to delays in treatment.…”

Commentary: Extended-Duration betrixaban reduces the risk of stroke versus standard-Dose enoxaparin among hospitalized medically Ill patients

“…Easy to use risk assessment models would provide a useful tool for clinicians to risk stratify their patients and facilitate the decision of whether or not to provide stroke prophylaxis for acutely ill patients at the time of hospital admission. Enrichment strategies may include treating patients with known risk factors for stroke such as atrial fibrillation, previous history of stroke or transient ischemic attack (TIA), hypertension, hyperlipidemia, obesity, and smoking [14][15][16] . Additionally, identifying feasible biomarkers that predict the occurrence of stroke may prove beneficial.…”