Date Published: April 12, 2019
Publisher: Public Library of Science
Author(s): Min-Yi Lu, Chih-Hao Chen, Shin-Joe Yeh, Li-Kai Tsai, Chung-Wei Lee, Sung-Chun Tang, Jiann-Shing Jeng, Juan Manuel Marquez-Romero.
In-hospital stroke (IHS) is an uncommon but serious medical emergency. Early recanalization through endovascular thrombectomy (EVT) may offer a vital therapeutic choice. This study compared the clinical features and outcomes between IHS and community-onset stroke (COS).
From a single-center registry of 2813 patients with ischemic stroke, those who had received EVT for acute ischemic stroke were included and classified into the IHS and COS groups based on their stroke onset scenario. We compared the outcomes including successful recanalization, symptomatic intracranial hemorrhage, functional independence (modified Rankin Scale score, 0–2) at 90 days, and mortality between the two groups.
A total of 24 patients with IHS (mean age, 70 years; 54% men) and 105 patients with COS (mean age, 73 years; 47% men) were included. The most frequently reported reasons for admission in patients with IHS were cardiovascular and oncological diseases. The initial National Institutes of Health Stroke Scale (NIHSS) scores and main occluded vessels were similar between the two groups. Patients with IHS received a higher number of active malignancy diagnoses, were more likely to withhold antithrombotic agents, and exhibited higher prestroke functional dependency. The median onset-to-puncture time was 192 min in IHS and 217 min in COS (P = 0.15). The percentages of successful recanalization (79% vs 71%), symptomatic hemorrhage (0% vs 9%), functional independence (42% vs 40%), and mortality (17% vs 12%) were comparable between the two groups. After adjustment for covariates, initial NIHSS scores and successful recanalization were the most important predictors for functional independence at 90 days.
Despite having disadvantages at baseline, patients with IHS could still benefit from timely EVT to achieve favorable outcomes. A well-designed acute stroke protocol tailored for IHS should be developed.
In-hospital stroke (IHS) is an uncommon but serious medical emergency. Between 6.5% and 15% of all strokes may occur in the hospital depending on whether population-based or hospital-based registries are considered [1–3]. Patients with IHS usually exhibit specific predisposing risk factors and conditions prone to development of stroke, such as ongoing cardiovascular disease and receipt of surgery or invasive procedures [2, 4]. Previous studies have demonstrated a considerable delay in evaluation and treatment of IHS and a unanimously worse functional outcome among patients with IHS [3–6]. Currently, endovascular thrombectomy (EVT) is the standard acute treatment for large vessel occlusion strokes, and appropriate imaging selection allows broader diagnosis for patients, further extending the time window for stroke therapy [7–9]. Because some patients with IHS may be ineligible for treatment with intravenous recombinant tissue plasminogen activator (rt-PA) due to comorbidities or contraindications, early recanalization through EVT becomes a vital therapeutic choice.
From January 2015 to December 2017, a total of 2813 patients with acute ischemic stroke were admitted to the study hospital. Of them, 2477 (88.1%) were categorized into the COS group and 336 (11.9%) were categorized into the IHS group. Patients with IHS were more likely to have heart disease, dyslipidemia, and cancer; their initial stroke severity was higher than those with COS (Table 1). Moreover, they were more likely to have stroke-in-evolution, higher 1-month mortality, and worse 3-month functional status. Furthermore, the proportion of patients who received intravenous thrombolysis were significantly lower in the IHS group than in the COS group (3.6% vs 7.3%, P = 0.01).
The present study found that, relative to patients with COS, in a hospital equipped with a well-designed protocol and trained personnel, patients with IHS treated with EVT can achieve similar workflow efficiency and comparable proportion of favorable outcomes. This finding was encouraging because most previous studies have suggested that patients with IHS had worse functional dependency [3–6], which was usually attributed to poor baseline function and delay in diagnosis and timely intervention. However, previous studies have included all IHS patients irrespective of whether they received acute recanalization treatment. Our study provided unequivocal evidence that when recanalization, the current most effective strategy, was indicated and accessible, the patients with IHS could still benefit substantially from it.
The present study demonstrated that despite having disadvantages at baseline condition, patients with IHS could still benefit from timely EVT. A well-designed acute stroke protocol tailored for IHS should be developed in each hospital for more favorable patient outcomes.