Inpatient and Community Ischemic Strokes in a University Hospital

Abstract

Background: Previous studies have shown that inpatient strokes are common and severe. We sought to characterize the risk factors, stroke subtypes, timing of acute stroke evaluation and frequency of thrombolytic therapy in inpatient ischemic strokes compared with community ischemic strokes. Design/Methods: The hospital records of patients admitted for acute ischemic stroke between 1996 and 2002 were reviewed. Acute stroke was defined as occurrence of stroke symptoms within 72 h, and in-hospital status was assigned if the patient was currently admitted for another illness at the time of the stroke. Patient demographics such as medical versus surgical service, admission diagnoses, clinical features including stroke risk factors, access to thrombolytic therapy and immediate outcome were analyzed. Results: Of 947 patients with acute ischemic stroke, 161 (17.0%) had strokes occurring while already in the hospital (IHIS), compared to 786 (83%) that occurred in the outpatient community (CIS). Approximately two thirds of IHIS occurred on medical services (102, 63.4%) and one third on surgical services (59, 36.7%). Mean age, male gender, atherothrombotic etiology and risk factors including hypertension, diabetes and smoking history were of similar frequencies in IHIS and CIS, but penetrating artery disease was the cause of only 5.6% of IHIS compared to 21.8% of CIS (p < 0.0001). The mean modified Rankin scale for IHIS at presentation was 4.33 ± 0.74, compared to 3.67 ± 1.03 for CIS (p < 0.0001). Of 161 IHIS patients, 21 (13.0%) had neurological assessment within 3 h of symptom onset, compared to 16.0% of CIS patients (p = 0.403, n.s.), and the rate of thrombolytic therapy was not significant between IHIS (3.7%) and CIS (5.6%) patients. Conclusions: IHIS are common and severer than CIS. The use of thrombolytic therapy in IHIS patients was limited because of time of recognition and inpatient-associated conditions. Increased vigilance for timely neurological assessment of these patients is warranted.

Quality of Care and Outcomes for In-Hospital Ischemic Stroke

“…[1][2][3][4][5][6] There are an estimated 35 000 to 75 000 of these in-hospital strokes in the United States each year. 7 Relatively little is known about the characteristics, treatments, quality of care, and outcomes of these patients.…”

In-hospital stroke

“…It is less known that between 2.2% and 17% of all strokes occur in hospitalized patients, with a lower percentage reported in smaller hospitals and multicenter studies 3,4 and higher rate in tertiary clinics 5,6 . This difference is presumably due to a higher percentage of critically ill patients in larger hospitals, more frequent high-risk procedures and, possibly, a lower rate of reported cases in some participating centers in multicenter studies.…”

“…The most common contraindications are recent major surgery, current and sufficient anticoagulation, recent bleeding or terminal illness 5,11 . In patients who can receive IVRTPA, however, IVRTPA has been shown to be equally safe in IHS and in COS 3 .…”

“…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.…”

Improving stroke alert response time: Applying quality improvement methodology to the inpatient neurologic emergency

“…1 Although inpatient strokes are thought to be under-recognized and under-reported, between 4% and 17% of all stroke patients in the hospital experienced stroke onset during hospitalization. 2,3 Estimates place the number of in-hospital strokes at 35,000-75,000 each year in the United States. 4 As a result of the exquisite sensitivity of brain tissue to ischemic events, stroke is a medical emergency and time-to-treatment is of the essence.…”