Hospital size, remoteness and stroke outcome

Introduction: Previous studies have shown an association between number of stroke admissions and outcomes. Small hospitals often support more remote areas and we studied national data to determine if an association exists between hospital remoteness and stroke care. Methods: Data from the Irish National Audit of Stroke (INAS) on average stroke admissions, adjusted mortality for ischaemic stroke, thrombolysis rate and proportion with door to needle (DTN) ≤45 min were analysed. Hospital remoteness was quantified by distance to the next hospital, nearest neurointerventional centre and location within 10 km of the national motorway network. Results: Data for 23 of 24 stroke services were evaluated. Median number of strokes admitted per year was 186 (range 84-497). Nine hospitals (39%) admitted ≥200 stroke patients per year (mean 332). Average adjusted mortality (7.0 vs. 7.3, P = 0.67 t-test), mean thrombolysis rate (12.1% vs. 9.2%, P = 0.09) and mean proportion of patients treated ≤45 min (40.4% vs. 31.3%, P = 0.2) did not differ significantly between higher and lower volume hospitals.Hospitals close to the motorway network (n = 15) had a higher mean thrombolysis rate (11.9% vs. 7.5%, P = 0.01 t-test) and proportion DTN ≤45 min (43.7-18.4%, P Conclusion: Remoteness of hospitals is associated with worse measures of stroke outcome and management.</p

Response to: Relationship between hospital size, remoteness and stroke outcome

We thank Dr Liu and Dr Wang for their consideration of our paper. In response to some of their comments, as the paper makes clear, the study was conducted in only Ischaemic strokes (1). Because of the small size of some of the participating hospitals and the smaller proportion of haemorrhagic strokes calculations of adjusted mortality rate are less precise in the haemorrhagic stroke population. There are also fewer effective acute interventions for intracerebral haemorrhage thus measures of process such as thrombolysis rate and door to needle time would not be pertinent to them. Subsequent analyses of the data have found that in fact Remote hospitals in Ireland see a lower proportion of haemorrhagic strokes and care for a slightly older population (2) but both of these factors were controlled for in the study.</p

Irish National Audit of Stroke: a critical review of national stroke data for Ireland from 2013 to 2021

In the European Union (EU) stroke is the second most common  cause of death and a leading cause of adult disability. As populations continue to grow and live to an older age, stroke and the long-term sequelae, along with the corresponding costs, are expected to increase dramatically (The Stroke Alliance for Europe, 2020; Bennett et al., 2014). Treatment for stroke has advanced greatly since the 1990s, and there is strong evidence that stroke unit care with multidisciplinary team input will reduce disability and mortality and will benefit all patients with a stroke. Patients with ischaemic stroke who present early after symptom  onset will benefit from emergency  treatments such as thrombolysis and thrombectomy (Organisation for Economic Co-operation and Development, 2015). </p

Irish National Audit of Stroke National Report 2020

Stroke remains the third leading cause of death in Ireland and Western Europe, and the leading cause of severe, adult-onset physical disability. We report on patients aged 17 years and over who were treated in the 24 public hospitals that provide acute stroke care in Ireland and that admit more than 25 stroke cases annually. Data are typically collected by stroke services on behalf of the participating hospitals. In order to be included in the audit report, hospitals must have collected data on more than 80% of patients with a stroke. This year’s report incorporates data from the 23 participating hospitals that met the mandatory 80% coverage threshold; overall, despite the effects of the coronavirus disease 2019 (COVID-19) pandemic, coverage improved from 83% to 93% across the hospital system for patients with a stroke identified through the Hospital In-Patient Enquiry (HIPE) system as having been admitted with acute stroke, either ischaemic or haemorrhagic. The audit does not currently collect data on subarachnoid haemorrhage; however, we are exploring how these data may be effectively incorporated in future years’ audits. Because of the increased coverage, the number of individuals on whom data have been collected increased by more than 20% in 2020 from 2019. This important increase in coverage does appear to have led to substantial changes in proportional outcomes for most variables, but caution should be exercised in interpretation of minor changes from previous years.</div

Irish National Audit of Stroke National Report 2019

INTRODUCTION Stroke is the third leading cause of death in Western Europe and is the leading cause of severe long-term adult disability (The Stroke Alliance for Europe, 2020). Stroke is an important health issue for people in Ireland, with approximately 5,500 adults admitted to hospitals with a stroke in 2019. Stroke can affect people physically, emotionally and socially. It has a significant impact on Health Service Executive (HSE) resources, accounting for up to 4% of total health expenditure annually (Health Information and Quality Authority, 2017a). Although the economic costs of stroke in terms of lost employment and the cost of support in the community are significant, the impact on family members or friends who care for stroke survivors is massive. It is therefore important that all hospitals providing acute stroke services deliver high-quality and equitable stroke care. </p

Symptomatic carotid atheroma inflammation Lumen-stenosis score compared with Oxford and Essen risk scores to predict recurrent stroke in symptomatic carotid stenosis

Background: The Oxford Carotid Stenosis tool (OCST) and Essen Stroke Risk Score (ESRS) are validated to predict recurrent stroke in patients with and without carotid stenosis. The Symptomatic Carotid Atheroma Inflammation Lumen stenosis (SCAIL) score combines stenosis and plaque inflammation on fluorodeoxyglucose positron-emission tomography (18FDG-PET). We compared SCAIL with OCST and ESRS to predict ipsilateral stroke recurrence in symptomatic carotid stenosis. Patients and methods: We pooled three prospective cohort studies of patients with recent (50%). All patients had carotid 18FDG-PET/CT angiography and late follow-up, with censoring at carotid revascularisation. Results: Of 212 included patients, 16 post-PET ipsilateral recurrent strokes occurred in 343 patient-years follow-up (median 42 days (IQR 13-815)).Baseline SCAIL predicted recurrent stroke (unadjusted hazard ratio [HR] 1.96, CI 1.20-3.22, p = 0.007, adjusted HR 2.37, CI 1.31-4.29, p = 0.004). The HR for OCST was 0.996 (CI 0.987-1.006, p = 0.49) and for ESRS was 1.26 (CI 0.87-1.82, p = 0.23) (all per 1-point score increase). C-statistics were: SCAIL 0.66 (CI 0.51-0.80), OCST 0.52 (CI 0.40-0.64), ESRS 0.61 (CI 0.48-0.74). Compared with ESRS, addition of plaque inflammation (SUVmax) to ESRS improved risk prediction when analysed continuously (HR 1.51, CI 1.05-2.16, p = 0.03) and categorically (ptrend = 0.005 for risk increase across groups; HR 3.31, CI 1.42-7.72, p = 0.006; net reclassification improvement 10%). Findings were unchanged by further addition of carotid stenosis. Conclusions: SCAIL predicted recurrent stroke, had discrimination better than chance, and improved the prognostic utility of ESRS, suggesting that measuring plaque inflammation may improve risk stratification in carotid stenosis.</p

Cohort profile: BIOVASC-late, a prospective multicentred study of imaging and blood biomarkers of carotid plaque inflammation and risk of late vascular recurrence after non-severe stroke in Ireland

Purpose: Inflammation is important in stroke. Anti-inflammatory therapy reduces vascular events in coronary patients. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) identifies plaque inflammation-related metabolism. However, long-term prospective cohort studies investigating the association between carotid plaque inflammation, identified on 18F-FDG PET and the risk of recurrent vascular events, have not yet been undertaken in patients with stroke. Participants: The Biomarkers Imaging Vulnerable Atherosclerosis in Symptomatic Carotid disease (BIOVASC) study and Dublin Carotid Atherosclerosis Study (DUCASS) are two prospective multicentred observational cohort studies, employing near-identical methodologies, which recruited 285 patients between 2008 and 2016 with non-severe stroke/transient ischaemic attack and ipsilateral carotid stenosis (50%-99%). Patients underwent coregistered carotid 18F-FDG PET/CT angiography and phlebotomy for measurement of inflammatory cytokines. Plaque 18F-FDG-uptake is expressed as maximum standardised uptake value (SUVmax) and tissue-to-background ratio. The BIOVASC-Late study is a follow-up study (median 7 years) of patients recruited to the DUCASS/BIOVASC cohorts. Findings to date: We have reported that 18F-FDG-uptake in atherosclerotic plaques of patients with symptomatic carotid stenosis predicts early recurrent stroke, independent of luminal narrowing. The incorporation of 18F-FDG plaque uptake into a clinical prediction model also improves discrimination of early recurrent stroke, when compared with risk stratification by luminal stenosis alone. However, the relationship between 18F-FDG-uptake and late vascular events has not been investigated to date. Future plans: The primary aim of BIOVASC-Late is to investigate the association between SUVmax in symptomatic 'culprit' carotid plaque (as a marker of systemic inflammatory atherosclerosis) and the composite outcome of any late major vascular event (recurrent ischaemic stroke, coronary event or vascular death). Secondary aims are to investigate associations between: (1) SUVmax in symptomatic plaque, and individual vascular endpoints (2) SUVmax in asymptomatic contralateral carotid plaque and SUVmax in ipsilateral symptomatic plaque (3) SUVmax in asymptomatic carotid plaque and major vascular events (4) inflammatory cytokines and vascular events.</p