Clinical characteristics of patients with early hospital arrival after stroke symptom onset.
ABSTRACT Identifying characteristics of early arrivers after stroke may be useful to improve delivery of acute stroke treatment. We sought to identify the clinical characteristics and outcomes of patients with ischemic stroke who present early after symptom onset using data collected from a representative sample of hospitals in the state of Georgia.
Data were obtained retrospectively from a statewide observational stroke registry from December 1, 2001, to February 28, 2002, and from February 1 to March 31, 2003. Clinical characteristics of patients with stroke arriving to the hospital within 2 hours were compared with those arriving later.
Of the 409 patients with ischemic stroke identified with a specified time of onset, 172 (42%) presented within 2 hours. Univariate analysis showed hospital arrival within 2 hours was associated with history of coronary artery disease (P = .0400), dyslipidemia (P = .0100), ambulance transport (P = .0285), stroke team consultation (P = .0070), higher National Institutes of Health Stroke Scale score (P < .0001), and lower Glasgow Coma Scale score (P = .0018). Race, sex, age, smoking history, previous stroke, myocardial infarction, congestive heart failure, prosthetic heart valve, hypertension, diabetes, and family history of stroke were not associated with arrival within 2 hours. Multivariate analysis revealed National Institutes of Health Stroke Scale score (odds ratio = 1.20, confidence interval 1.08-1.34, P = .0013) and Glasgow Coma Scale score (odds ratio = 0.84, confidence interval 0.75-0.94, P = .0027) were associated with arrival within 2 hours. Patients with stroke arriving within 2 hours had higher in-hospital mortality (13% v 4%) (P = .0284), but a higher rate of independent ambulation at discharge (55% v 37%) (P = .0419).
Early arrival after ischemic stroke symptom onset is associated with increased stroke severity, higher mortality, and better functional outcome.
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ABSTRACT: During the first 30 days after a stroke, the case fatality is about 25% and the major cause of death is the index stroke and its sequelae. The most consistent predictor of 30-day mortality after stroke is stroke severity. Other predictors include increasing age, a history of previous stroke, cardiac failure, and a high blood glucose concentration and white blood cell count. Other less common, but important, causes of early mortality are recurrent ischaemic stroke and a coronary event. The risk of a recurrent cerebrovascular event is highest in the first month (4%) and year (12%) after a stroke and transient ischaemic attack (TIA), probably reflecting the presence of active, unstable atherosclerotic plaque. Thereafter, the risk of a recurrent cerebrovascular event falls to about 5% per year, similar to the risk of a coronary event. During years 1-5 after a TIA and ischaemic stroke, cardiovascular disease increasingly becomes the major cause of death, reflecting the generalized nature of atherothrombosis, the most common cause of the index stroke. The most robust predictor of death within 1-5 years after stroke is increasing age, closely followed by cardiac failure. Additional baseline predictors of longer-term mortality include a history of previous symptomatic atherothrombosis (TIA, ischaemic stroke, peripheral arterial disease, and early-onset ischaemic heart disease), risk factors for atherothrombosis (smoking), other heart diseases (cardiac failure, atrial fibrillation) and increasing stroke severity. Lacunar syndromes can be predictive of relative longevity. At 5 years after stroke, survival is about 40%, and about half of survivors are disabled and dependent. The most robust predictors of disability at 5 years after stroke are increasing age, stroke severity, and recurrent stroke. The most powerful predictor of early recurrent stroke (within 30 days after stroke) is an atherosclerotic ischaemic stroke caused by large-artery atherosclerosis with >50% stenosis, whereas the strongest predictor of stroke recurrence over 5 years is diabetes. Other predictors of recurrent stroke include increasing age, previous TIA, atrial fibrillation, high alcohol consumption, haemorrhagic index stroke, and hypertension at discharge. The clinical implication of these findings is that strategies for optimizing long-term outcome after TIA and stroke should be directed toward reducing the high risk of recurrent stroke and coronary events by removing/recanalizing the symptomatic atherosclerotic plaque, controlling the underlying causal vascular risk factors, and administering long-term, effective antiplatelet therapy.Cerebrovascular Diseases 02/2003; 16 Suppl 1:14-9. · 2.81 Impact Factor
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ABSTRACT: To delineate components of delay within the hospital ED for patients presenting with symptoms of stroke. A prospective registry of patients presenting to the ED with signs or symptoms of stroke was established at a university hospital from July 1995 to March 1996. The ED arrival time, time to being seen by an emergency physician (EP), time to CT scan, and time to neurology consultation were obtained by medical record review. The median delay (interquartile range) from ED arrival to being seen by an EP for the 170 eligible subjects was 0.42 (0.20-0.75) hours. The median delay to CT scan was 1.88 hours (1.25-2.67) and the median delay to neurology consultation was 2.42 hours (1.50-3.48). Age, race, sex, and hospital discharge diagnosis had little influence on delay. Subjects arriving by emergency medical services (EMS) had a significantly shorter time to being seen by an EP (0.33 vs 0.50 hours) when compared with those who arrived by other means. Time to CT scan was shorter by 0.5 hours for patients arriving by EMS as well. These differences persisted when stratified by out-of-hospital delay times. These data suggest that arriving by EMS is associated with shorter times to being seen by an EP and receiving a CT scan. The influence of EMS on delays associated with rapid medical care of stroke patients reaches beyond the out-of-hospital transport phase.Academic Emergency Medicine 04/1999; 6(3):218-23. · 1.76 Impact Factor
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ABSTRACT: The effectiveness of stroke treatment depends on the time interval between onset of symptoms and admission to hospital. The purpose of our investigation was to assess, over a 10-year period, the mean delay in admission to hospital in stroke patients to determine factors which might be associated with this delay, to define the putative number of patients available for accrual in clinical trials, and to identify strategies aimed at decreasing the time to admission. We collected data on all stroke patients consecutively admitted to our clinic from 1986 to 1995. The following variables were investigated: age, sex, educational and occupational level, home accommodation, family and personal history of vascular disease or factors known to affect the risk of vascular disease, and type and severity of stroke. The individual and independent contribution of these variables was assessed by univariate and multivariate analysis. The accurate time of stroke onset was established for 760 patients. Of these, 24.7% were admitted within 1 h from the onset of symptoms, 41% within 2 h, 54% within 4 h and 72.5% within 12 h. The mean delay was 21 +/- 2 h (SE) and the median was 3.5 h. Acute onset of neurological deficits, stroke severity and family history of cerebrovascular disease were associated with earlier presentation. According to the current guidelines for thrombolytic therapy, only 16% of the patients could have been included in a clinical trial. This study suggests that despite a relatively short time to hospital admission in most patients and an altered help-seeking behavior over time, many stroke patients did not present early enough to be recruited for clinical trials or to benefit from new treatments. The majority of patients with timely presentation were not eligible for acute treatment, or were subjects with severe stroke for whom caution is advised before initiating thrombolytic therapy. It has been suggested that the patient's indecision to seek medical help is the most important reason for a delayed hospital admission of stroke patients. These results underscore the importance of interventions aimed at reducing the delay in stroke treatment induced by patients who are unaware of the decisive role of the time of treatment induction. The finding that earliest admissions for stroke comprised patients with a previous history of cerebrovascular disease suggests that an education campaign might highlight the importance of an early admission.Neuroepidemiology 02/1999; 18(5):255-64. · 2.37 Impact Factor