In-Hospital Stroke in a Multidisciplinary Hospital

Introduction. Acute cerebrovascular event (ACVE) is the leading cause of persistent disability and death in the world. Due to the high medical and social significance, much attention is paid to the problem of out-of-hospital stroke, and the issues of diagnostics and treatment of in-hospital stroke are practically not studied.

Relevance. In-hospital stroke is defined as stroke that develops in a patient hospitalized for other reasons. It is known that the incidence of in-hospital stroke ranges from 2 to 19% of all acute cerebrovascular accidents recorded in the hospital, 0.04–0.06% of all hospital admissions. It was found that patients with inhospital stroke have significant restrictions on thrombolytic therapy, mortality can reach 60%, and the diagnosis is often made with long delays and deviations in examination protocols. The most common pathogenetic subtype of in-hospital ischemic stroke is the cardioembolic subtype. The explanation for this is that in most cases, in-hospital ischemic strokes develop in patients after open cardiac surgery with prosthetics of one or more valves, bypass surgery in conditions of artificial circulation, carotid endarterectomy. In the overwhelming majority of patients, the first symptoms of in-hospital stroke are observed not by doctors, but by nurses, patients or their relatives. Mortality in in-hospital stroke is significantly higher than in non-hospital stroke, which is due to the high incidence of extracerebral complications in this cohort of patients, as well as initially more severe stroke.

Aim of study. To analyze the incidence of in-hospital stroke and the tactics of its treatment in a multidisciplinary hospital.

Material and methods. The study included 975 patients with ACVE hospitalized at the N.V. Sklifosovsky Research Institute for Emergency Medicine from January 1, 2018 to January 1, 2019. The inclusion criterion was any case of CVE - out-of-hospital or in-hospital. The study did not include patients with subarachnoid hemorrhage (SAH) where secondary cerebral ischemia developed against the background of vasospasm. Also, we did not include patients with stroke, transferred from other hospitals for neurosurgical treatment.

Results. In total, in 2018 at the N.V. Sklifosovsky Institute ACVE were diagnosed in 975 patients, of which in-hospital and out-of-hospital strokes were diagnosed in 109 (11.2%) and 866 patients (88.8%), respectively. The proportion of in-hospital stroke was 0.03% of the total number of patients treated at the institute in 2018. Systemic thrombolytic therapy (sTLT) is the main method of treating patients with IS. However, patients with in-hospital stroke may have a large number of contraindications to this type of therapy. Systemic TLT was performed in 1 patient (1%) with in-hospital stroke, while in out-of-hospital stroke, thrombolysis was performed in 36 patients (4.7%). After analyzing the reasons for refusing to perform sLT in patients with in-hospital and out-of-hospital IS. The leading reason for the impossibility of sTLT in patients with in-hospital stroke was the unspecified time of disease development - 44 (43.2%). In 35 patients (34.3%) with in-hospital stroke, refusal to perform sLTT was associated with late IS diagnosis, despite the fact that the stroke developed in the hospital.

Conclusion. Thus, an in-hospital stroke aggravates the course of the underlying disease and, as a consequence, the outcome of the disease, leads to an increase in social and medical and economic costs. In this regard, there is a need to study the prevalence, risk factors, clinical features of in-hospital stroke, as well as the development of diagnostic and therapeutic algorithms in order to improve the efficiency of care for patients with in-hospital stroke.

1. Mendis S, Puska P, Norvving B. Global Atlas on Cardiovascular Disease Prevention and Control. Geneva: World Health Organization Publications; 2013. Available at: https://www.paho.org/hq/dmdocuments/2013/WHO-Global-Atlas-CVD-2011-eng.pdf [Accessed 02 Nov 2020]

2. Cumbler E. In-Hospital Ischemic Stroke. Neurohospitalist. 2015;5(3):173–181. PMID: 26288675. https://doi.org/10.1177/1941874415588319

3. Blacker DJ. In-hospital Stroke. Lancet Neurol. 2003;2(12):741–746. PMID: 14636779. https://doi.org/10.1016/s1474-4422(03)00586-6

4. Farooq MU, Reeves MJ, Gargano J, Wehner S, Hickenbottom S, Majid A. In-Hospital Stroke in a Statewide Stroke Registry. Cerebrovasc Dis. 2008;25(1–2):12–20. PMID: 18033953. https://doi.org/10.1159/000111494

5. Saltman AP, Silver FL, Fang J, Stamplecoski M, Kapral MK. Care and Outcomes of Patients with In-Hospital Stroke. JAMA Neurol. 2015;72(7):749–755. PMID: 25938195. https://doi.org/10.1001/jamaneurol.2015.0284

6. Schürmann K, Nikoubashman O, Falkenburger B,Tauber SC, Wiesmann M, Schulz JB, Reich A. Risk Profile and Treatment Options of Acute Ischemic In-Hospital Stroke. J Neurol. 2016;263(3):550–557. PMID: 26762395. https://doi.org/10.1007/s00415-015-8010-2

7. Filimonova PA. Klinicheskie i etiopatogeneticheskie osobennosti vnutribol’nichnykh ostrykh narusheniy mozgovogo krovoobrashcheniya v mnogoprofil’nom statsionare: cand. med. sci. diss. synopsis. Ekaterinburg; 2018. (In Russ.) Available at: https://search.rsl.ru/ru/record/01008714605 [Accessed 02 Nov 2020]

8. Moradiya Y, Levine SR. Comparison of Short-term Outcomes of Thrombolysis for In-hospital Stroke and Out-of-hospital Stroke in US. Stroke. 2013;44(7):1903–1908. PMID: 23632981. https://doi.org/10.1161/STROKEAHA.113.000945

9. Aly N, McDonald K, Leathley M, Sharma A, Watkins C. Retrospective Case Note Review of Acute and Inpatient Stroke Outcomes. BMJ. 2000;320(7248):1511–1512. PMID: 10834893. https://doi.org/10.1136/bmj.320.7248.1511

10. Kimura K, Minematsu K, Yamaguchi T. Characteristics of In-Hospital Onset Ischemic Stroke. Eur Neurol. 2006;5 5(3):155–159. PMID: 16733355. https://doi.org/10.1159/000093574

11. Masjuan J, Simal P, Fuentes B, Egido JA, Díaz-Otero F, Gil-Núñez A, et al. In-Hospital Stroke Treated With Intravenous Tissue Plasminogen Activator. Stroke. 2008; 39(9):2614-2616. PMID: 18635852. https://doi.org/ 10.1161/STROKEAHA.107.512848

12. Cumbler E, Murphy P, Jones WJ, Wald HL, Kutner JS, Smith DB. Quality of Care for In-Hospital Stroke: Analysis of a Statewide Registry. Stroke. 2011;42(1):207–210. PMID: 21127301. https://doi.org/10.1161/STROKEAHA.110.590265

13. Kolomentsev SV, Odinak MM, Voznyuk IA, Tsygan NV, Yanishevsky SN, Golokhvastov SYu, et al. Ischemic Stroke in Hospitalized Patients. The Modern View on the Problem. Bulletin of the Russian Military Medical Academy. 2017;2(58):206–212. (In Russ.)

14. Vera R, Lago A, Fuentes B, Gállego J, Tejada J, Casado I, et al. In- Hospital Stroke: A Multi-Centre Prospective Registry. Eur J Neurol. 2011;18(1):170–176. PMID: 20550562. https://doi.org/10.1111/j.1468-1331.2010.03105.x

15. Manawadu D, Choyi J, Kalra L. The Impact of Early Specialist Management on Outcomes of Patients with In-Hospital Stroke. PLoS ONE. 2014; 9(8):e104758. PMID: 25144197. https://doi.org/10.1371/journal.pone.0104758

16. Stamou SC, Hill PC, Dangas G, Pfister AJ, Boyce SW, Dullum MK, et al. Stroke after Coronary Artery Bypass: Incidence, Predictors, and Clinical Outcome. Stroke. 2001; 32(7):1508–1513. PMID: 11441193. https://doi.org/10.1161/01.str.32.7.1508

17. Gutsche TJ, Cheung AT, McGarvey ML, Moser WG, Szeto W, Carpenter JP, et al. Risk Factors for Perioperative Stroke After Thoracic Endovascular Aortic Repair. Ann Thorac Surg. 2007; 84(4):1195–1200. PMID: 17888969. https://doi.org/10.1016/j.athoracsur.2007.04.128

18. Koennecke HC, Belz W, Berfelde D, Endres M, Fitzek S, Hamilton F, Kreitsch P, et al. Factors Influencing In-Hospital Mortality and Morbidity in Patients Treated on a Stroke Unit. Neurology. 2011;77(10):965–972. PMID: 21865573. https://doi.org/10.1212/WNL.0b013e31822dc795

19. Dong Y, Cao W, Cheng X, Fang K, Zhang X, Gu Y, et al. Risk Factors and Stroke Characteristic in Patients with Postoperative Strokes. J Stroke Cerebrovasc Dis. 2017; 26(7):1635–1640. PMID: 28478979. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.12.017

20. Vlisides PE, Mashour GA, Didier TJ, Shanks AM, Weightman A, Gelb AW, Moore LE. Recognition and Management of Perioperative Stroke in Hospitalized Patients. AA Case Rep. 2016;7(3):55–56. PMID: 27490452. https://doi.org/10.1213/XAA.0000000000000342

21. Adelman E, Meurer WJ, Nance DK, Kocan MJ, Maddox KE, Morgenstern LB, et al. Stroke Awareness Among Inpatient Nursing Staff at an Academic Medical Center. Stroke. 2014;45(1):271–273. PMID: 24135928. https://doi.org/10.1161/STROKEAHA.113.002905

22. Alberts MJ, Brass LM, Perry A, Webb D, Dawson DV. Evaluation Times for Patients With In-Hospital Strokes. Stroke. 1993;24(12):1817–1822. PMID: 8248961. https://doi.org/10.1161/01.str.24.12.1817

23. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ricard Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304–377. PMID: 28101605. https://doi.org/10.1007/s00134-017-4683-6