New research was presented at ISC 2016, the International Stroke Conference, from February 17 to 19 in Los Angeles. The features below highlight some of the studies emerging from the conference that are relevant to emergency medicine.
Analyzing Telestroke Consultations
The Particulars: Telestroke consultations have been widely available for several years in the United States. However, large-scale outcomes data on the ability of telestroke to improve acute treatment in rural systems of care are lacking.
Data Breakdown: For a study, researchers reviewed data from more than 3,000 acute ischemic stroke (AIS) patients who were treated via tele-emergency consults at 46 U.S. hospitals between 2012 and 2015. Among participants who received tPA, nearly three-quarters were treated within 180 minutes from being last seen normal (LSN). Almost 17% of patients received tPA within 4.5 hours of LSN. The average door-to-needle time was 83 minutes, with 22% receiving tPA within 60 minutes. The average time from patient arrival to telestroke call initiation was 44 minutes, and the average call to video consult time was 20 minutes.
Take Home Pearls: Access to telestroke consultations in rural hospitals appears to result in relatively high levels of treatment with tPA among AIS patients. While teleconsultation physician response times appear to be quick, patient arrival to telestroke call times tend to be much longer.
Hypertension Not Linked With ICH
The Particulars: Recent research suggests that intracerebral hemorrhage (ICH) often occurs shortly after an acute rise in blood pressure. However, whether patients discharged from the ED with hypertension are at increased risk for ICH in subsequent weeks has not been well studied.
Data Breakdown: American investigators compared the odds of ICH during days 8 through 38 after ED discharge with the odds during days 373 through 403 after discharge among more than 550,000 patients with a primary diagnosis of hypertension. Less than 0.02% were diagnosed with ICH during either time period. Whereas patients aged 60 and older and those with secondary discharge diagnoses other than hypertension had increased odds of ICH, absolute risks were low in all subgroups.
Take Home Pearl: Patients with ED visits for hypertension do not appear to have an increased short-term risk for ICH after discharge.
EMS Partnership Reduces DTN Time
The Particulars: Guidelines suggest that tPA be administered within 60 minutes of arrival among stroke patients. However, barriers often prevent this goal from being achieved. Partnering with emergency medical services (EMS) may help reduce door-to-needle (DTN) time for tPA.
Data Breakdown: Researchers developed an intervention to reduce DTN times in which EMS took acute stroke patients directly to CT on their stretchers and drew blood prior to patients arriving at the hospital. During the 3 months following initiation of the intervention, door-to-CT times dropped 6 to 10 minutes, and door-to-lab receipt times decreased by 7 to 10 minutes. DTN times for tPA decreased from an average of 65 minutes in the 3 months prior to the intervention to 50 minutes in the 3 months after. At 4 months following initiation of the intervention, the average DTN time was 34 minutes.
Take Home Pearl: Partnering with EMS in the care of acute stroke patients appears to lower DTN times and may improve patient care.
Dysphagia Screening Benefits AIS Patients
The Particulars: The Joint Commission has mandated that patients with acute ischemic stroke (AIS) undergo dysphagia screening when presenting to the hospital to help avoid pneumonia. Although most AIS patients present to the ED, evidence is lacking on whether screening for dysphagia in the ED helps reduce rates of pneumonia in this patient population.
Data Breakdown: AIS patients who received care without being screened in the ED for dysphagia were compared with cohorts who underwent such screening for a study. Rates of dysphagia during hospitalization were 20% for those who did not undergo screening and 31% for those who did. Patients who underwent dysphagia screening had a significantly lower rate of pneumonia than those who did not (8.0% vs 13.8%).
Take Home Pearls: Screening for dysphagia in the ED appears to be feasible and is associated with a lower rate of pneumonia in AIS patients when compared with no screening. However, additional research is required to determine whether a causal relationship exists between ED dysphagia screening and decreased rates of pneumonia.
Stroke Unit Admission & Bed Availability
The Particulars: Guidelines recommend that all patients with acute stroke be admitted to stroke units as the first level of care. Little is known regarding if reducing hospital bed capacity—as a result of economic constraints—affects quality of stroke care.
Data Breakdown: To investigate if acute stroke patients are less likely to be directly admitted to a stroke unit when hospital beds are scare, researchers analyzed data on nearly 14,000 of these types of patients. The odds of patients being directly admitted to a stroke unit decreased by 1.5% for every percentage increase in hospital bed occupancy that exceeded 90.0%. The best-performing hospitals had an odds-ratio of 3.8 for admitting patients to a stroke unit directly, compared with hospitals with the most stroke admissions during the study period.
Take Home Pearls: Acute stroke patients appear to be less likely to be admitted directly to a stroke unit when hospital beds are scarce. Differences seen between hospitals suggest that organizational changes at the hospital level may affect stroke care quality.
Disparities in Post-Stroke Functional Status
The Particulars: Evidence suggests that functional outcomes after stroke are considered important to patients. However, the risk factors for poor functional outcomes following stroke have not been well defined in clinical research.
Data Breakdown: Study investigators assessed 90-day functional outcomes for patients with ischemic or hemorrhagic stroke or transient ischemic attack (TIA). Several factors were associated with worse functional outcomes in these patients, including:
- Being a woman.
- Being non-Caucasian.
- Having higher stroke severity scores.
After adjusting for stroke severity, female gender and non-Caucasian race were associated with poorer functional status. A trend was also seen for worse functional status among patients with a prior stroke or TIA.
Take Home Pearl: Stroke severity, being a woman, being an ethnic minority, and having had a prior stroke appear to be important risk factors for poor functional status 3 months after a stroke.
Stroke & Long-Term Seizure Risk
The Particulars: Researchers have hypothesized that stroke may be associated with a similar long-term risk of seizures as traumatic brain injury (TBI), a well-established risk factor for long-term seizure disorders. However, few studies have assessed the long-term risk of seizures after stroke.
Data Breakdown: For a study, researchers compared the rate of ED visits or hospitalizations with a discharge diagnosis of seizure over 2.5 years follow-up among stroke patients with the rate among those who had experienced a TBI. Stroke patients had a seizure rate of 37.6%, compared with a rate of 29.9% among TBI patients. The cumulative rates of any seizure were:
- 26.2% following subarachnoid hemorrhage.
- 33.6% following ischemic stroke.
- 35.0% following intracerebral hemorrhage.
Take Home Pearls: More than one-third of stroke patients appear to experience a seizure during the 2.5 years following their stroke. The long-term risk of seizure after stroke appears to be similar to the risk after a TBI, a well-established risk factor for long-term seizure.
New-Onset Depression Following Ischemic Stroke
The Particulars: Research has shown that depression is common following a stroke. However, data are lacking on the occurrence and correlates of developing depression among stroke survivors without a pre-stroke history of depression.
Data Breakdown: For a study, new-onset depression post-stroke (NDPS) was assessed for the 5 years following stroke among post-menopausal women who were stroke-free at enrollment and had no self-reported history of depression. Among those who had an ischemic stroke, 21.4% had NDPS. Rates of NDPS ranged from 16.7% for those with good recovery to 31.5% for those who were severely disabled. Rates of NDPS ranged from 19.1% for those with lacunar infarction to 45.8% for those with total anterior circulation infarction. When compared with low optimism, a moderate level of optimism was associated with reduced odds of NDPS among those with ischemic stroke and good recovery.
Take Home Pearls: Among postmenopausal women, NDPS appears to be common. Psychological factors, particularly optimism, appear to play a role in reducing NDPS.
AF Monitoring in Stroke Survivors
The Particulars: Research suggests that atrial fibrillation (AF) is a recurrent ischemic stroke risk factor that is often undiagnosed in acute stroke patients who present in sinus rhythm. Enhanced and prolonged Holter-ECG-monitoring, initiated early after stroke, may increase AF detection rates and allow for early oral anticoagulation to effectively prevent recurrent ischemic events.
Data Breakdown: Ischemic stroke patients participating in a study were randomized to intensified and enhanced rhythm monitoring (IEM) by means of repeated 10-day Holter-ECG-monitoring after 0, 3, and 6 months (IEM group) or to standard-of-care AF-detection according to current stroke guidelines (control group). Rates of detected AF at 6 months were 13.5% for the IEM group and 4.5% for the control group. No additional cases of AF were detected between 6 and 12 months in the IEM group, compared with four new diagnoses of AF in the control group.
Take Home Pearl: Repeated 10-day Holter-ECG monitoring, initiated early after ischemic stroke, appears to be superior to standard care in detecting AF within 6 months in ischemic stroke patients.
Assessing Benefits With Virtual Reality for Stroke Rehab
The Particulars: Small, single-center studies indicate modest benefits in motor recovery after stroke with the use of virtual reality rehabilitation. Multicenter trials to confirm these results are lacking.
Data Breakdown: At 12 stroke rehabilitation units participating in a study, adult stroke patients were randomized to receive virtual reality rehabilitation using the Nintendo Wii gaming system or recreational activities (card-playing, Jenga, and dominoes) for 10 60-minute sessions. Both groups showed improvements in average time to complete a functional status test. No significant differences were observed between groups following the intervention or at 4 weeks follow-up.
Take Home Pearl: Among stroke survivors, virtual reality as an add-on to conventional rehabilitation does not appear to provide any significant benefits in functional status when compared with recreational activities.
For more information on these studies and others that were presented at ISC 2016, visit http://my.americanheart.org/professional/Sessions/InternationalStrokeConference/International-Stroke-Conference_UCM_316901_SubHomePage.jsp.