Journal of Stroke and Cerebrovascular Diseases

BackgroundDischarge destination after acute ischemic stroke has implications for functional recovery and healthcare costs. Individuals discharged to inpatient rehabilitation facilities (IRFs) achieve better outcomes than those discharged to skilled nursing facilities (SNFs); however, many patients discharged to IRFs and SNFs have similar clinical profiles. We examined non-clinical factors associated with discharge location after acute ischemic stroke. MethodsPopulation: 236 adults hospitalized with acute ischemic stroke, living independently in the community prior to admission, and discharged to either an IRF (n=171) or SNF (n=65). Clinical variables: NIHSS, Charlson Comorbidity Index (CCI), acute care length of stay (LOS), functional status (AM-PAC "6-Clicks"), and neglect. Non-clinical variables: age, sex, race, marital status, insurance, home layout, living status, and available assistance. Associations with discharge location were evaluated using univariable and multivariable logistic regression and reported as odds ratios (OR) with 95% confidence intervals (CI). ResultsIndividuals discharged to IRFs were younger, more likely to cohabitate, and had shorter LOS than those discharged to SNFs. Functional status (AM-PAC) and comorbidity burden (CCI) did not differ significantly between groups despite differences in discharge destination. In univariable models, younger age, cohabitating marital status, living with family, available assistance, shorter LOS, private insurance, and higher NIHSS were associated with greater odds of IRF discharge. In multivariable analysis, younger age (OR 0.94, 95% CI 0.91-0.98), cohabitating marital status (OR 2.46, 95% CI 1.13-5.48), and shorter LOS (OR 0.88, 95% CI 0.82-0.93) remained independently associated with IRF discharge. ConclusionsIndividuals with comparable pre-stroke independence and similar clinical severity, discharge to IRF versus SNF was independently associated with non-clinical factors; age, marital status, and LOS, whereas stroke severity and functional status were not significant predictors. These findings underscore the importance of evidence-informed discharge criteria integrating clinical indicators and social context to support equitable access to intensive rehabilitation after stroke.

BackgroundWhile prehospital triage protocols for suspected large vessel occlusion (LVO) improve ischemic stroke outcomes, their impact on spontaneous intracerebral hemorrhage (sICH) remains uncertain. We evaluated whether a regional LVO-focused emergency medical service (EMS) transport protocol affected care efficiency and outcomes in sICH patients. MethodsWe conducted a multicenter pre-post implementation cohort study using the Get-With-The-Guidelines-Stroke database in Chicago (April 2017-January 2020). Included were EMS-transported sICH patients arriving [≤]6 hours from last known normal at 8 comprehensive stroke centers (CSCs) and 15 primary stroke centers (PSCs). Primary outcomes were in-hospital mortality and favorable discharge disposition (home/acute rehabilitation). Secondary outcomes included good neurologic outcome (independent ambulation) at discharge and time metrics (symptom-to-arrival, door-to-CT). Interrupted time series (ITS) analysis assessed changes while accounting for temporal trends. ResultsAmong 311 sICH patients (111 pre-, 192 post-implementation), there was no difference in in-hospital mortality (12% vs. 9%, p=0.4; ITS level change: -5% [95% CI: -31% to 21%], p=0.68; trend change: 1% [95% CI: -1% to 2%], p=0.34), favorable discharge disposition (58% vs. 64%, p=0.3; ITS level change: -20% [-77% to 38%], p=0.49; trend change: 1% [95% CI: -2% to 4%], p=0.47) or good neurologic outcomes (13% vs. 19%, p=0.4; ITS level change: 11% [-25% to 48%], p=0.53; trend change: -1% [95% CI: -3% to 1%], p=0.37) between pre-post implementation periods. Time metrics (door-to-CT, symptom-to-arrival, symptom-to-CT) showed no significant changes in unadjusted or ITS analyses. The protocol also did not impact CSC admissions rate and inter-hospital transfers in ITS analyses. ConclusionImplementation of an LVO-focused EMS transport protocol did not improve outcomes or care efficiency among sICH patients, nor did it affect CSC admission or transfer rates. These findings highlight the need for dedicated prehospital triage strategies specific to sICH, distinct from ischemic stroke pathways.

Documented Goals of Care Conversations with Hospitalized Patients after Severe StrokeO_ST_ABSBackgroundC_ST_ABSIdentifying goals of care is important for patients suffering severe ischemic stroke (SIS) and their caregivers to ensure patient- and family-centered treatment decisions. This study sought to determine the prevalence and patient predictors associated with having a documented goals-of-care conversation (dGOCC) after SIS. MethodsWe reviewed the medical charts of all patients with National Institutes of Health Stroke Scale (NIHSS) [≥]10 admitted to four hospitals in the Midwestern US. In addition to sociodemographic and clinical characteristics, we searched for dGOCC during the acute stroke hospitalization, defined as any documented conversation or meeting that addressed one or more of the following domains: prognostic information, treatment plan, patient preferences and values, quality of life, or establishing goals. We determined prevalence, frequency, timing, and content of dGOCCs. Additionally, we obtained information on treatment utilization and outcomes. ResultsAmong 1297 patients, 26.5% (n=344) had at least one dGOCC. Treatment plan was the most discussed domain (n=264, 20% of all patients) and was the most common first dGOCC (n=207, 60% of first conversations). Median day for first dGOCC was on hospital day zero. Patient preferences, values, and goals were documented in 112 (8.6%) of all patients charts and quality of life conversations were documented in only 61 (4.7%) charts. In multivariate analysis, having a NIHSS [≥]21 (OR 1.46, p-value.01) was associated with having a dGOCC. ConclusionAfter severe stroke, most patients do not have a dGOCC, despite the important decisions that often arise about treatment and rehabilitation. Documentation of patient preferences, values and goals are even rarer. This suggests missed opportunities for high quality decision making informed by patient goals to improve person centered care.

BackgroundStroke recurrence rates following an index event remain high compared with the baseline population. Evidence-based stroke treatments reduce this risk. AimsTo determine the effect of an updated and streamlined hospital stroke guideline on prescribing practices and stroke recurrence rates at 3 months. MethodsHospital registries were searched for ICD-10 codes for transient ischaemic attack (TIA) and ischaemic stroke between July 2019 and July 2020. Data on patient demographics, discharge documentation, and other outcomes of interest were dichotomised into pre and post-intervention. Results396 patients were identified. There was a significant reduction in the stroke recurrence rate at 3 months post guideline update (8.3% vs 2.2%, OR 0.24, p<0.01). There were significant improvements in prescriptions for statins (66.5% vs 81.2%, p[&le;]0.01) and antihypertensives (40.7% vs 50.7%, p=0.05), and documentation of lipid and blood pressure targets in discharge letters. There was a trend towards greater use of dual antiplatelet therapy (25.2% vs 34.1%, p=0.057). ConclusionIn this audit, we found an association between the guideline update and improved patient outcomes and prescribing practices. We were unable to directly attribute the reduction in stroke recurrence to any single factor. This may be a chance finding and warrants investigation in other settings.

BackgroundStroke is a major cause of death and disability in India. Despite national programs and guidelines, stroke care continues to face challenges. Many stroke patients seek care at government medical colleges. To date, there are no studies from India that comprehensively assessed the quality of acute stroke care. This study aims to evaluate acute stroke care in its pre-implementation phase across 22 medical colleges using key indicators for optimal care. MethodsIMPETUS stroke is a multicentric, prospective, multiphase, mixed-methods, quasi-experimental implementation study, comprising three phases, initiated in October 2021. During its pre-implementation phase, a baseline assessment of the existing components of stroke care was performed using pre-structured case report form, among prospectively enrolled acute stroke patients at 22 medical colleges. ResultsA total of 2,018 patients were enrolled during the pre-implementation phase. Mean (SD) age was 59 (14) years with male preponderance (64%); 69% had an onset <24 hours, majority had ischemic stroke (60%), followed by ICH (38%). Key risk factors were hypertension (80%), diabetes (30%), smoking (22%), alcohol abuse (24%) and previous stroke (21%). Imaging performed: CT (69%), CTA (18%) and MRA (14%). Intravenous thrombolysis was administered in 39% eligible, predominantly with TPA (72%). In-hospital delay was the most common reason for not receiving thrombolysis (44%). The status of stroke time metrics (in minutes) was: onset-to-door 660 (IQR 285-1682), door-to-CT 95 (IQR 46-274), onset-to-needle 201 (165-250), CT-to-needle 36 (23-50), and door-to-needle time 67 (48-90). Other important stroke care indices were also evaluated. In-hospital mortality was 19% and 33% of patients achieved modified Rankin scale score 0-2 at 90-days. ConclusionThese comprehensive data provide a representative baseline status of acute stroke care in India, which will be useful in comparing advancements of stroke care during the implementation phase of the study and improve policy making.

BACKGROUNDStroke-associated pneumonia (SAP) is a common poststroke complication but the influence of early neurological deterioration (END) on SAP risk remains unclear. We aimed to develop an easy-to-access model to predict SAP and evaluate the SAP-END relationship using the Glasgow Coma Scale (GCS). METHODSThis retrospective study enrolled consecutive patients aged [&ge;]20 years with first-ever acute ischemic stroke at Kaohsiung Veterans General Hospital between January 1, 2010, and November 30, 2020. SAP was defined according to modified Centers for Disease Control and Prevention criteria. Patients baseline characteristics, laboratory data within 24 h, neurological findings, and serial GCS scores within 48 h were collected. Regression analysis was used to identify independent risk factors for SAP. RESULTSAmong 1009 enrolled patients, SAP occurred in 85 (8.4%) patients. Using multivariate analysis, END after admission (adjusted odds ratio [aOR] 2.94, 95% confidence interval [CI] 1.74-4.95, P<0.001) remained significant after adjusting for confounders. Initial GCS score <10 (aOR 2.30, 95% CI 1.30-4.06, P=0.004), National Institutes of Health Stroke Scale (NIHSS) score 5-15 (aOR 2.02, 95% CI 1.09-3.73, P=0.026) or [&ge;]16 (aOR 3.45, 95% CI 1.72-6.89, P<0.001), cardioembolism (aOR 4.76, 95% CI 1.90-11.91, P=0.014), undetermined etiology (aOR 3.41, 95% CI 1.29-9.03, P=0.001), and neutrophil-to- lymphocyte ratio (NLR) >2.5 (aOR 2.10, 95% CI 1.28-3.46, P=0.004) were also significant. The area under the curve (AUC) of combined GCS score, END, NIHSS score, cardioembolism, stroke with undetermined type, and NLR was 0.83 (95% CI 0.78-0.87, P<0.001), which was superior to that of PANTHERIS scores (0.62, 95% CI 0.55-0.68, P<0.001). CONCLUSIONSThis study developed a simple predictive model for SAP using easily accessible and generally available parameters. GCS-based END was an independent risk factor for SAP. Early identification of SAP risk factors and reversible END causes may lower SAP incidence.

Background and purposeIn 2018 a stroke care pathway (SCP) was introduced in Norway. The goal of the pathway was to improve acute stroke care by reducing time-delay. We aimed to evaluate if achieving the target times of the SCP was associated with a better functional outcome at 3 months post-stroke and to identify characteristics of patients attaining the goals. MethodsWe performed a register-based study with data from the Norwegian stroke register (NSR). Patients registered with acute stroke in 2019 were included. Functional outcome at 3 months in the patients with "achievement" was compared to patients with "non-achievement". Achievement was defined as attaining three important goals in the SCP; 1) time from symptom onset to contact with the emergency medical service, 2) time from symptom onset to arrival in hospital, 3) time from arrival in hospital to admission to a stroke unit. Additionally, we evaluated time from arrival in hospital to treatment with intravenous thrombolysis. Modified Rankin Scale (mRS) was used to measure functional outcome at 3 months post-stroke and functional independence was defined as mRS 0-2. Characteristics of the "achievers" were analysed by univariate and multivariate logistic regression analyses. ResultsIn total 2818 patients were included, 460 (16%) were in the achievement group. The mean (SD) age was 72.5 (12.6) years and 1201 (43%) were women. The probability of being independent at 3 months post-stroke was significantly higher in the achievement group versus the non-achievement group (OR 1.36, 95% CI 1.04-1.79, p=0.026). The "achievers" were significantly younger, less likely to be living alone, less likely to have diabetes, more often had an ischemic stroke and were admitted with more severe strokes than the "non-achievers". ConclusionGoal achievement in the SCP was significantly associated with independence 3 months post-stroke.

BackgroundLinking emergency medical services (EMS) and hospital stroke registry data is crucial for evaluating stroke systems of care, but the impact of different linkage methods on selection bias remains unclear. This study compared deterministic and probabilistic linkage approaches and assessed their effects on sample representativeness and analytical conclusions MethodsIn this cross-sectional study we analyzed 13,567 stroke patients transported by EMS to 40 Kentucky hospitals participating in Get With The Guidelines - Stroke (2021-2023). Records were linked using deterministic and probabilistic methods. We compared match rates, assessed sample representativeness, and evaluated the impact of selection bias using inverse probability weighting. ResultsDeterministic and probabilistic methods achieved match rates of 73.0% and 78.7%, respectively. Both methods produced similar representative samples, with modest differences between matched and unmatched cases primarily in race and admission year. Accounting for selection bias had minimal impact on the estimated associations between EMS stroke recognition and outcomes (percent change in adjusted odds ratios < 1%). ConclusionsWhile probabilistic linkage yielded modestly higher match rates, both methods produced comparable results with minimal selection bias. When working with high-quality data with low missingness, deterministic linkage may be sufficient for many analyses, though sensitivity analyses remain important for assessing potential bias.

The therapeutic journey of patients affected by a stroke cause health impacts and deaths. Stroke is an acute neurological dysfunction, classified as hemorrhagic or ischemic. This study aimed to compare the therapeutic journey in the access of patients affected by stroke in hospitals in the Brazilian Northeast. Prospective cohort study, carried in all public hospitals that had a neuroimaging service in the State of Sergipe. The collection instrument sought sociodemographic characterization and timeline. The data were exported to the R Core Team 2022 software. After being coded and tabulated, they were analyzed using descriptive statistics. The hypothesis of independence was tested using Pearson Chi-Square and Fisher Exact tests. A total of 159 patients cared for in the hinterland region of the State and 91 in the capital city (Aracaju) participated in the study, with a median age of 66 years old (SD:55.5-75) in the capital and with a median age of 72 years old (SD:60-82) in the hinterland. There was a predominance in females, 76.6% and 64.1%, respectively. It was found a higher incidence of the ischemic stroke (IS) (p<0.002). The decision time between the onset of signs and symptoms and the decision to call up transportation, it was observed that patients with IS cared for in the hinterland take three times longer (p=0.002). Regarding the time between the stroke detection and the CT scan, it was five times longer for those from the hinterland (p<0.001) in cases of IS. In cases of HS, the time was 1.4 longer for those from the hinterland. Concerning the neurological evaluation, in cases of IS and HS, the rates found were 76.6% vs 78.3% in the hinterland, while 100% of patients were evaluated for both types of stroke episodes in the capital city (p<0.001). The therapeutic journey of patients cared for in the hinterland of the State has a longer period of time.

BACKGROUNDDespite advancements in neurosurgery and intensive care that reduce overall mortality, poor-grade aneurysmal subarachnoid haemorrhage (aSAH) (World Federation of Neurosurgical Societies [WFNS] grades IV and V) remains a significant clinical challenge and is associated with persistently high mortality rates. The aim of this study was to assess the long-term outcomes of poor-grade aSAH and to identify factors influencing patient prognosis to guide clinical management. METHODSA multicentre, observational cohort study was conducted across 12 regional centres in northern China. The study included patients with poor-grade aSAH admitted from 2017 to 2020. The baseline data included demographics, clinical presentation, aneurysm characteristics, and treatment modalities. Outcome data, including survival status, mortality along with its associated causes and timing, and modified Rankin scale (mRS) scores, were collected prospectively at the last medical follow-up. Changes in case fatality over time were quantified with weighted linear regression. Survival analysis was performed to estimate survival and hazard ratios for death. Binary logistic regression was performed to estimate the odds ratio for dependency (mRS=3-5). RESULTSAmong the 1,589 enrolled patients, 1,339 were successfully followed, with an average follow-up of 26.37 months. Among them, 61.5% (824/1,339) were dependent or died. The overall mortality rate was 51% (684/1,339), and 21.3% (140/655) of the survivors were dependent. The risk factors for mortality included age [&ge;]65 years, previous history of stroke, and WFNS grade V. Additionally, conservative treatment and endovascular treatment were identified as risk factors and protective factors, respectively, compared with surgical treatment. WFNS grade V and middle cerebral artery aneurysms are independent risk factors for dependency. CONCLUSIONSAlthough there has been a downward trend in recent years, the long-term mortality rate for poor-grade aSAH has remained significantly high at 51%, with 21.3% of survivors being dependent. Active aneurysm treatment, to the extent possible, is crucial for improving the prognosis of these patients.

The middle cerebral artery occlusion (MCAO) suture model is widely accepted ischemic stroke model. However, researchers routinely use young male rats, ignoring that stroke risk is increased in older, post-menopausal women. To this end, we implemented (120-minute) transient- and permanent-occlusion MCAO models in female retired-breeder rats, examining the endpoint across 1-30 days to identify the optimal time course for the model. We found that in both groups the physical infarct (measured by triphenyltetrazolium chloride -TTC staining), which is present initially, was not detectable 30 days post-MCAO (even if some neurologic symptoms persist). Across shorter time-points (namely 24 hours and 7 days) we found that neurologic scores generally reach a plateau/maximum at {bsim}7 days, then infarct size gradually decreases over time for rats receiving a permanent MCAO. Across 3 transient occlusion times (60 minutes, 90 minutes, and 120 minutes), the longest gave the most robust result. Overall, the permeant and 120-minute transient MCAO evaluated at 7 days was optimal. Using these two models, we evaluated the neuroprotective qualities of the antibiotic, minocycline. We found that those in the treatment groups experienced a greater improvement in neurologic scores and a larger decrease in infarct size after daily treatment for seven days. This improvement was more prominent in the transiently occluded treatment group than in the permanently occluded group.

BackgroundLittle is known on the burden of ICU care for stroke patients. The aim of this study was to provide a description of management strategies, resource use, complications and their association with prognosis of stroke patients admitted to ICU. MethodsUsing a population-based stroke registry, we analyzed consecutive stroke patients admitted to 3 ICU with at least one organ failure between 2008 and 2017. The study period was divided into two periods corresponding to the arrival of mechanical reperfusion technique. Predictors of ICU mortality were separately assessed in two multivariable logistic regression models, a "clinical model" and an "intervention model". The same analysis was performed for predictors of functional status at hospital discharge. Results215 patients were included. Stroke etiology was ischemia in 109 patients (50.7%) and hemorrhage in 106 patients (49.3%). Median NIHSS score was 20.0 (9.0; 40.0). The most common reason for ICU admission was coma (41.2%) followed by acute circulatory failure (41%) and respiratory failure (27.4%). 112 patients (52%) died in the ICU and 20 patients (11.2%) had a good functional outcome (mRS[&le;]3) at hospital discharge. In the "clinical model," factors independently associated with ICU mortality were: age (OR = 1.03 [95%CI, 1.0 to 1.06]; p=0.04) and intracranial hypertension (OR = 6.89 [95%CI, 3.55 to 13.38]; p<0.0001). In the "intervention model," the need for invasive mechanical ventilation (OR = 7.39 [95%CI, 1.93 to 28.23]; p=0.004), the need for vasopressor therapy (OR = 3.36 [95%CI, 1.5 to 7.53]; p=0.003) and decision of withholding life support treatments (OR = 19.24 [95%CI, 7.6 to 48.65]; p<0.0001) were associated with bad outcome. ConclusionOur study showed the very poor prognosis of acute stroke patients admitted to ICU. These results also suggest that the clinical evolution of these patients during ICU hospitalization may provide important information for prognostication.

BackgroundBlood pressure variability (BPV) following endovascular thrombectomy (EVT) in AIS has been associated with poor outcome. Variables that predict high BPV must be examined to improve outcome. The purpose of this study is to analyze predictors and effect of BPV on outcome in patients with good recanalization after EVT. MethodsWe conducted a retrospective analysis of prospectively collected data from an IRB approved registry of two academic Comprehensive Stroke Centers between 2017-2022. Patients were included if they had 1) anterior circulation large vessel occlusions (LVO) and 2) EVT with TICI 2b-3. All BPs were recorded as immediate pre-op SBP/DBP (one minute prior to procedure), immediate post-op SBP/DBP (at time of recanalization), and 24 hours post revascularization. Demographic variables, stroke time metrics, and symptomatic ICH (sICH) were assessed. Outcome included discharge disposition and 90 day modified Rankin Scale. Good short-term outcome was disposition to home/acute rehabilitation and good long-term outcome was mRS 0-2. BPV was the average of the differences between measurements divided by the number of measurements. R ResultsWe identified 253 patients (mean age 70{+/-}14, 51.4% female, 49% white, 30.4% Hispanic). Median NIHSS was 17{+/-}8 and mean onset to groin puncture was 478{+/-}326 mins. Mean door to groin puncture was 86{+/-}110 mins. Good discharge occurred in 58.9% of patients. Mean BPV was 30.6{+/-}25.6mmHg and was significantly correlated with female sex, home antihypertensive use, and immediate pre and post-op SBP. BPV was not associated with age, initial NIHSS, Hispanic ethnicity, HTN, sICH, discharge disposition or 90 day mRS. ConclusionThere was a significant correlation of high BPV with female sex and home antihypertensives use. BPV was not correlated with short or long term outcome in this population, however, BPV was lower than prior populations. Assessment of BPV in various stroke centers and populations is necessary to understand the effect of BPV on stroke outcome.

BackgroundImpairment in cerebral autoregulation has been proposed as a potentially targetable factor in patients with aneurysmal subarachnoid hemorrhage (aSAH), however there are different continuous measures that can be used to calculate the state of autoregulation. In addition, it has previously been proposed that there may be an association of impaired autoregulation with the occurrence of spreading depolarization (SD) events. MethodsSubjects with invasive multimodal monitoring and aSAH were enrolled in an observational study. Autoregulation indices were prospectively calculated from this database as a 10 second moving correlation coefficient between various cerebral blood flow (CBF) surrogates and mean arterial pressure (MAP). In subjects with subdural ECoG (electrocorticography) monitoring, SD was also scored. Associations between clinical outcomes using the mRS (modified Rankin Scale) and occurrence of either isolated or clustered SD was assessed. Results320 subjects were included, 47 of whom also had ECoG SD monitoring. As expected, baseline severity factors such as mFS and WFNS (World Federation of Neurosurgical Societies scale) were strongly associated with the clinical outcome. SD probability was related to blood pressure in a triphasic pattern with a linear increase in probability below MAP of [~]100mmHg. Autoregulation indices were available for intracranial pressure (ICP) measurements (PRx), PbtO2 from Licox (ORx), perfusion from the Bowman perfusion probe (CBFRx), and cerebral oxygen saturation measured by near infrared spectroscopy (OSRx). Only worse ORx and OSRx were associated with worse clinical outcomes. ORx and OSRx also were found to both increase in the hour prior to SD for both sporadic and clustered SD. ConclusionsImpairment in autoregulation in aSAH is associated with worse clinical outcomes and occurrence of SD when using ORx and OSRx. Impaired autoregulation precedes SD occurrence. Targeting the optimal MAP or cerebral perfusion pressure in patients with aSAH should use ORx and/or OSRx as the input function rather than intracranial pressure.

BackgroundThe translation of standard-of-care in acute ischemic stroke reperfusion interventions into practice is well established, but multifactorial obstacles exist in the complete adoption, which has led to inequities in access and delivery of services. The objective of this study was to improve access and efficiency of ischemic stroke treatment across four Atlantic Canadian Provinces. MethodsA stepped-wedge cluster trial was conducted over 30 months with 3 clusters covering 34 sites. The trial was conducted across all 4 Atlantic Canadian provinces: Nova Scotia (NS), New Brunswick (NB), Prince Edward Island (PE), and Newfoundland and Labrador (NL). The design was quasi-randomized, with each cluster associated with one or more provinces: cluster 1 - NS; cluster 2 - NB and PE; and cluster 3 - NL. The patient population was all ischemic stroke patients across all 4 provinces. The intervention was a 6-month modified Quality Improvement Collaborative (mQIC), which was modified from the Breakthrough Series Collaborative to be half of the 1-year period and conducted virtually. The intervention consisted of assembling an interdisciplinary improvement team, 2 full-day workshops, webinars, and virtual site visits. Suggested changes included 6 process improvement strategies. ResultsOver the trial period, 8594 ischemic stroke patients were included, out of which 1576 patients received acute treatment. The proportion of patients that received treatment did not increase significantly with the intervention [0.4% increase for patients that received thrombolysis and/or EVT (p=0.68)]. Median door-to-needle time was reduced by 9.2 minutes with the intervention (p=0.01). Cluster 3 saw the greatest improvements in both access and efficiency. ConclusionsA mQIC intervention resulted in improvement of process measures like door-to-needle time. Quality improvement initiatives may need to be longer to allow full implementation and tailored for each health system to ensure that each system sees improvement. In-person activities might be critical to ensure fidelity of the intervention.

BackgroundWhile endovascular thrombectomy (EVT) is considered as the most effective treatment for a select group of patients with acute ischemic stroke and large vessel occlusion, its safety and efficacy in older patients are still debated especially in "read-world" settings. This study reports outcomes of EVT in acute ischemic stroke patients aged 90 and older in our community hospital setting. MethodsData between January 2018 and December 2022 were aggregated for all acute ischemic stroke patients with aged 90 and older at the time of EVT. Thirty-one patients met the criteria and were included in this report. The data valuables included, but are not limited to, demographics, stroke risk factors, thrombolysis in cerebral infarction (TICI), modified Rankin Scale (mRS), and NIH Stroke Scale (NIHSS). ResultsAll 31 patients had improvement in TICI scale. One had symptomatic intracranial hemorrhage after EVT not related to the procedure, but likely on the basis of reperfusion breakthrough. Three patients expired prior to their discharge from non-stroke related causes. Of remaining 28, four expired, six went into hospice care, and four lost to follow-up by 30-days post DC. Of six hospice cases, one expired by 90-day post DC, and additional three were lost to follow-up. Given this data, 20/27 (74%) survived to 30 days and 16/24 (67%) to 90 days. For their NIHSS symptomatic categories, 15/28 (54%) patients improved, 10/28 (36%) remained the same, and 3/28 (11%) declined. For mRS, at 30-days post DC, 7/24 (30%) patients showed improvement, 7/24 (30%) remained the same, and 10/24 (40%) declined. At 90-days post DC, 7/21 (33%) showed improvement from DC, 4/21 (19%) remained the same, and 10/21 (48%) declined. ConclusionsWhile a larger cohort study is necessary, our report supports the safety and efficacy of EVT in this patient aged 90 and older in a real-world setting.

Introduction: Intracerebral hemorrhage (ICH) carries higher morbidity and mortality than ischemic stroke. Recent studies have demonstrated improved patient outcomes by applying ultra-early bundled interventions including blood pressure management, coagulopathy reversal, and osmotic therapy. Effective strategies to deliver these ultra-early treatment options are currently being explored. On December 19th, 2022, the Mayo Clinic Comprehensive Stroke Center (CSC) launched the "ICH Phases'' communication system to accelerate ICH patient care. Objective: To evaluate adherence to the AHA/ASA guidelines in acute ICH care following the implementation of our novel-tiered paging system. Methods: We retrospectively reviewed patients admitted with spontaneous ICH during 2024 and 2025. We excluded traumatic cases. We extracted clinical data such as time to imaging, documentation of ICH score, blood pressure control, reversal of anticoagulation, venous thrombo-embolism (VTE) prophylaxis and discharge disposition. Results: Among 67 patients, 68.7% underwent CT imaging within 25 minutes. We documented the ICH score within 6 hours in 82.9% of patients. Nearly 94.7% of patients with SBP>140 mm Hg received antihypertensive therapy, yet only 18% reached target BP within 60 minutes. We completed the reversal of anticoagulation within 120 minutes in 75% of patients. VTE prophylaxis was initiated within 24 hours in 91% of patients. Discussion: Our novel system demonstrated adherence to the AHA/ASA guidelines, and time sensitive benchmarks in neuroimaging, reversal of anticoagulation, and VTE prophylaxis. Early BP control remains a challenge, that highlights the discrepancy between guidelines and real-ground implementation. Conclusion: A novel tiered paging system is effective for enhancing early ICH care. Such a holistic system remains critical for sustained improvement in quality of care.

Background and PurposeSingle Small Subcortical Infarction (SSSI) is a subtype of ischemic stroke with unique pathophysiology, often leading to poor outcomes. This study investigates the association between admission hematocrit (HCT) levels and the risk of progressive stroke in SSSI patients. MethodsWe conducted a retrospective cohort study using data from the China National Stroke Registry III, including 2,457 SSSI patients. Progressive stroke was defined as an increase in the NIHSS score by [&ge;]2 points during hospitalization. Logistic regression models assessed the association between HCT levels and progressive stroke risk. ResultsAmong 2,457 SSSI patients, 135 (5.50%) experienced progressive stroke. Higher HCT levels were independently associated with a lower risk of progressive stroke (adjusted OR 0.983, 95% CI 0.973-0.994, P = 0.002), with a potential dose-response relationship. The protective effect was more pronounced in patients with severe sensory deficits (P for interaction = 0.013) and younger age (<65 years) (P for interaction = 0.037). Lower HCT levels were also independently associated with increased mortality risk within 3 months after stroke (adjusted OR 0.937, 95% CI 0.892-0.984, P < 0.001). ConclusionsHigher admission HCT levels are associated with a lower risk of progressive stroke in SSSI patients, particularly those with severe sensory deficits and younger age. Lower HCT levels may also increase early mortality risk. These findings highlight the importance of monitoring and optimizing HCT levels in SSSI management. Further research should explore the underlying mechanisms and therapeutic implications.

BackgroundEarly neurological deterioration within 24 h after thrombolysis in patients with acute ischemic stroke (AIS) is associated with poor outcomes. Evidence is lacking regarding neurological deterioration within 1 h after thrombolysis. MethodsPatients who received intravenous thrombolysis with tissue plasminogen activator (tPA) for AIS between January 2018 and December 2021 were consecutively enrolled. Very early neurological deterioration (VEND) was defined as a [&ge;] 4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score within 1 h after starting thrombolysis compared with the pre-treatment score. A modified Rankin Scale score of 3-6 at 3 months was defined as a poor functional outcome. ResultsOf the 353 AIS patients (age 69.7 {+/-} 13.3 years, 57% men) receiving thrombolysis with tPA, 29 (8.4%) had VEND. VEND was associated with symptomatic intracranial atherosclerotic disease (ICAD) (41% vs. 17%, P = 0.005) and was an independent predictor of poor functional outcomes at 3 months (adjusted odds ratio 3.04, P = 0.043). The VEND group had higher NIHSS scores at 1 h (19.2 {+/-} 7.3 vs. 9.0 {+/-} 7.1, P < 0.001) and 24 h (14.1 {+/-} 9.8 vs. 7.3 {+/-} 7.5, P = 0.001) after initiating tPA than the non-VEND group. In patients with an initial NIHSS score < 6, VEND was significantly associated with ICAD, receiving endovascular thrombectomy (EVT), and poor functional outcomes. In patients with VEND, EVT with successful recanalization led to lower NIHSS scores at 24 h than in those without successful recanalization (12 {+/-} 9 vs. 26 {+/-} 7, P = 0.047), and 24-h NIHSS scores predicted poor functional outcomes. ConclusionsIn patients receiving thrombolysis, VEND was independently associated with poor functional outcomes. Identifying VEND is crucial for underlying ICAD and salvageability by EVT. Successful recanalization by EVT effectively reduced 24-h stroke severity in patients with VEND.

Background and AimsGuidelines by the AHA/ASA recommend the development of stroke systems of care yet do not provide specifics as to how this should be done. As a first step in developing a regional stroke system of care in the "Stroke Belt" we sought to understand how high performing stroke systems across the world were organized in order to identify best practices and opportunities for meaningful system improvement. MethodsAn 81-question survey was developed to examine current practices in high-performing stroke systems. Twenty stroke centers worldwide were invited to participate. The survey encompassed all aspects of stroke systems of care from acute care and EMS practices to IT and discharge. Data analysis was conducted using REDCap internal analytic tools. ResultsNine of 20 invited centers (45%) completed the questionnaire. Responding centers reported annual averages (median) of 750 ischemic strokes (range 350-1444) and 125 (100-501) hemorrhagic strokes, 150 (60-440) IV alteplase administrations, and 55 (12-130) endovascular thrombectomy procedures. At all 9 systems, EMS providers are trained in identifying stroke and utilize prehosptial stroke scales. Six (66.7%) reported destination protocols based on stroke severity involving bypass to endovascular thrombectomy capable (EVT-C) centers. All centers report expedited referral hospital transfer processes for neurointervention. Five (55.6%) centers reported patients with confirmed large vessel occlusions bypass the emergency department and are transported directly to the neurointerventional suite. ConclusionsThis international survey reveals useful practice patterns and processes used by progressive stroke systems. This information will be integrated into our regional system of care quality improvement program.