In-Hospital Stroke in a Statewide Stroke Registry

Abstract

Background:In-hospital stroke (IHS) represents 5–15% of all hospitalized acute stroke cases, and is associated with poor outcomes. IHS represents an important area for prevention since many cases occur in high-risk patients undergoing cardiovascular procedures. Our objectives were to compare the quality of care, treatments, and outcomes of IHS with out-of-hospital stroke (OHS) cases. Methods: A 6-month prospective cohort of IHS and OHS stroke cases from a statewide acute stroke registry of 15 representative hospitals was assembled. Data were abstracted on demographic, clinical characteristics, in-hospital care (including tPA treatment), discharge instructions, and in-hospital outcomes (mortality and modified Rankin Scale [mRS] at discharge). Results:177 (6.5%) of the 2,743 cases in the registry were IHS cases. 40% of IHS cases were admitted with a cardiovascular or neurologically related problem, and 68% underwent an invasive diagnostic or surgical procedure prior to their stroke. IHS cases were less likely to have the cerebral vasculature examined or to have a lipid panel drawn. Compared to OHS, IHS had higher case fatality (14.6 vs. 6.9%; p = 0.04), greater functional impairment (mRS ≧4) (61 vs. 36%; p < 0.001), and were less likely to be discharged home (23 vs. 52%, p < 0.01). Conclusions:In this prospective registry, 1 in 15 acute stroke cases occurred in the hospital, and almost 70% had an invasive procedure undertaken prior to their stroke event. In-hospital cases received similar quality of care as OHS cases, but had significantly worse outcomes.

Comparison of the characteristics for in‐hospital and out‐of‐hospital ischaemic strokes

“…Although embolism and cardiac diseases have been known to be more common with IHS [11], few studies have compared risk factors for stroke between IHS and OHS [4]. This study shows that cardiac disease is more frequent in IHS patients, whilst hypertension, smoking, and dyslipidemia, which are well-known risk factors for atherosclerosis, were less commonly noted.…”

“…To determine etiologies, examination of cerebrovasculatures by using angiographic studies and/or Doppler studies is necessary. However, patients with IHS were less likely to have their cerebrovasculature investigated [4], whereas patients with OHS are typically admitted to the neurology department and are evaluated by standardized imaging protocols for cerebrovasculature examination. Patients with in-hospital attacks may occasionally have incomplete evaluations partly because of their underlying medical and surgical conditions, which results in less attention to the necessity of vascular studies by physicians on medical or surgical wards.…”

“…The high mortality and greater neurologic severity in IHS patients has previously been addressed [3,4,23]. The poor prognosis of IHS patients might be ascribed to the severity of co-morbid diseases and the high frequency of cardioembolic infarctions.…”

“…Stroke subtypes were investigated in 44 IHS patients who did not have surgical or medical procedures. The subtypes in those 44 patients included large artery atherosclerosis in three patients (6.8%), cardioembolism in 17 patients (38.6%), small vessel occlusion in two patients (4.5%), and stroke of undetermined etiology (due to incomplete evaluation in seven patients [15.9%], negative evaluation in 13 patients [29.5%], and more than two causes identified in two patients [4…”

“…Although IHS may have characteristics distinct from ischaemic stroke that occurs outside of a hospital (out-of-hospital stroke; OHS), information on the characteristics of IHS, particularly in comparison with OHS, is limited. A higher frequency of underlying cardiac diseases such as myocardial infarction and congestive heart failure were found in IHS [4]. However, data on etiologic stroke subtypes based on a widely used stroke classification system is lacking.…”