Search

BACKGROUND AND PURPOSE The relationship between lipid levels and the prognosis of acute intracerebral hemorrhage (ICH) remains controversial. Thus, we aimed to investigate whether lower low-density lipoprotein cholesterol (LDL-C) levels increased the risk of adverse outcomes, as well as the current situation of statin treatment in acute ICH patients with premorbid lipid-lowering therapy. METHODS From August 1, 2015, to July 31, 2019, a total of 73,098 ICH patients were included in our study from the Chinese Stroke Center Alliance program. Patients were grouped by LDL-C levels of 2.6 mmol/L. Logistic regression was used to assess the association between LDL-C levels and the composite risk of hematoma expansion (HE) or in-hospital death. Moreover, statin treatment in ICH patients with cardio-cerebrovascular diseases was analyzed. RESULTS In total, 6368 (8.7%) patients were identified as a composite of HE or in-hospital death with a mean LDL-C level of 2.9 ± 1.7 mmol/L. In the univariate analysis, patients who achieved lower LDL-C concentrations under 1.4 mmol/L had a 36% higher risk of adverse outcomes compared with the ≥ 2.6 mmol/L group (OR 1.36, 95%CI 1.23-1.51). Similar results were obtained in multivariate analyses, especially for patients with GCS scores of 9-15. For acute ICH patients with concomitant atherosclerotic disease, statin treatment was discontinued in the majority of Chinese population. CONCLUSIONS Lower LDL-C levels (

Background and purpose: We performed a systemic review and meta-analysis to elucidate the effectiveness and safety of dual antiplatelet (DAPT) therapy with P2Y12 inhibitors (clopidogrel/ticagrelor) and aspirin versus aspirin monotherapy in patients with mild ischemic stroke or high-risk transient ischemic attack. Methods: Following Preferred Reported Items for Systematic Review and Meta-Analysis standards for meta-analyses, Medline, Embase, Cochrane Central Register of Controlled Trials, and the Cochrane Library were searched for randomized controlled trials that included patients with a diagnosis of an acute mild ischemic stroke or high-risk transient ischemic attack, intervention of DAPT therapy with clopidogrel/ticagrelor and aspirin versus aspirin alone from January 2012 to July 2020. The outcomes included subsequent stroke, all-cause mortality, cardiovascular death, hemorrhage (mild, moderate, or severe), and myocardial infarction. A DerSimonian-Laird random-effects model was used to estimate pooled risk ratio (RR) and corresponding 95% CI in R package meta. We assessed the heterogeneity of data across studies with use of the Cochran Q statistic and I 2 test. Results: Four eligible trials involving 21 493 participants were included in the meta-analysis. DAPT therapy started within 24 hours of symptom onset reduced the risk of stroke recurrence by 24% (RR, 0.76 [95% CI, 0.68–0.83], I 2 =0%) but was not associated with a change in all-cause mortality (RR, 1.30 [95% CI, 0.90–1.89], I 2 =0%), cardiovascular death (RR, 1.34 [95% CI, 0.56–3.17], I 2 =0%), mild bleeding (RR, 1.25 [95% CI, 0.37–4.29], I 2 =94%), or myocardial infarction (RR, 1.45 [95% CI, 0.62–3.39], I 2 =0%). However, DAPT was associated with an increased risk of severe or moderate bleeding (RR, 2.17 [95% CI, 1.16–4.08], I 2 =41%); further sensitivity tests found that the association was limited to trials with DAPT treatment duration over 21 days (RR, 2.86 [95% CI, 1.75–4.67], I 2 =0%) or ticagrelor (RR, 2.17 [95% CI, 1.16–4.08], I 2 =37%) but not within 21 days or clopidogrel. Conclusions: In patients with noncardioembolic mild stroke or high-risk transient ischemic attack, DAPT with aspirin and clopidogrel/ticagrelor is more effective than aspirin alone for recurrent stroke prevention with a small absolute increase in the risk of severe or moderate bleeding.

Rationale Minor ischemic stroke attack has taken a significant part of cerebrovascular disease burden. Benefits of thrombolysis in minor stroke is under debates and the use of urokinase in developing countries needs to be further explored. Aim TRUST (ThRombolysis of Urokinase for minor STroke) trial was designed to evaluate the efficacy and safety of intravenous urokinase for the treatment of acute minor ischemic stroke. Sample size estimates To reach a double-sided type I error rate of 0.05 to test our hypothesis, with β = 0.80, sample size of 1002 subjects were determined after further adjustment to account for up to 5% nonadherence. Methods and design TRUST trial was developed with PROBE design, as a multicenter, randomized, open label, single-blind clinical trial with the stage of phase 3b. Study outcomes The proportion of patients retaining full ability of independent living, which is defined as patients scoring 0–1 on modified Rankin Scale score at 90 days. Discussion TRUST trial may potentially provide promising and affordable thrombolysis for acute minor ischemic stroke in the developing parts of the world.

Background and purposeCurrent randomised controlled trials (RCTs) showed an uncertain benefit of haemostatic therapy on preventing haematoma expansion and improving the outcome in patients with intracerebral haemorrhage (ICH). This meta-analysis aims to systematically evaluate the effect of haemostatic agents on the prevention of haemorrhage growth in patients with high-risk spontaneous ICH predicted by CT signs in RCTs.MethodsA comprehensive search of PubMed, EMBASE and Cochrane library from 1 January 2005 to 30 June 2021 was conducted. RCTs that compared haemostatic agents with placebo for the treatment of spontaneous patients with ICH with high-risk haemorrhage growth were included. The primary endpoint was haematoma expansion at 24 hours. Other major endpoints of interest included 90-day functional outcome and mortality.ResultsThe meta-analysis included four RCTs that randomised 2666 patients with ICH with high-risk haemorrhage growth. Haemostatic therapy reduced the rate of haematoma expansion at a marginally statistically significant level when compared with placebo (OR 0.84; 95% CI 0.70 to 1.00; p=0.051). Subgroup analysis for patients with black hole sign on CT revealed a significant reduction of haematoma expansion with haemostatic therapy (OR 0.61; 95% CI 0.39 to 0.94; p=0.03). However, both the primary analysis and subgroup analyses showed that haemostatic therapy could not reduce the rate of poor functional outcome (modified Rankin Scale >3) or death.ConclusionsHaemostatic therapy showed a marginally significant benefit in reducing early haematoma expansion in patients with high-risk spontaneous ICH predicted by markers on CT scan. However, no significant improvement in functional outcome or reduction of mortality was observed.

Objective: We aimed to investigate factors related to in-hospital mortality (IHM) in acute ischemic stroke (AIS) patients. Methods: We prospectively investigated 827,314 patients who were admitted ...

ObjectiveGastrointestinal (GI) bleeding in patients who had a stroke is strongly associated with a higher risk of death and loss of independence. However, it is unknown whether GI bleeding increases risk for recurrence of stroke. In this study, we assess the potential relationship between GI bleeding and stroke recurrence in patients within 12 months of an acute ischaemic stroke (AIS), using the China National Stroke Registry (CNSR).MethodsThis study included 22 216 patients who had an ischaemic stroke included in the CNSR from 2007 to 2008. We analysed baseline patient characteristics, GI bleeding and outcomes of patients who had an AIS, specifically stroke recurrence at 3, 6 and 12 months. We used multivariable logistic regression to evaluate a possible association between GI bleeding and stroke recurrence.ResultsOf the 12 415 patients included in our study, 12.3%, 15.5% and 17.7% had a stroke recurrence at 3, 6 and 12 months, respectively. GI bleeding was an independent stroke recurrence risk factor in patients after ischaemic stroke at 3 months (adjusted OR 1.481, 95% CI 1.118 to 1.962), 6 months (adjusted OR 1.448, 95% CI 1.106 to 1.896) and 12 months (adjusted OR 1.350; 95% CI 1.034 to 1.763).ConclusionGI bleeding was associated with the increased risk of stroke recurrence after an AIS.

Background Prior studies have shown an increased risk of ischemic stroke (IS) after myocardial infarction (MI); however, there are limited studies concerning the characteristics, in‐hospital mortality, and complications of patients with IS with a medical history of MI. We hypothesized that patients with IS with a medical history of MI may experience more severe strokes and have a higher risk of in‐hospital mortality and complications than patients with IS without a medical history of MI. Methods and Results Consecutive in‐hospital data were extracted from the China Stroke Center Alliance database from August 2015 to July 2019. Patient characteristics, hospital tests, in‐hospital mortality, and complications were analyzed and compared in patients with IS with or without a history of MI. Of 893 429 patients with IS, we identified 81 646 (9.1%) patients with a history of MI (MI group). Compared with patients with IS without MI, MI group patients were older, had a lower prevalence of current smoking, had a higher prevalence of a relative medical history, and took more medications before admission. Compared with the group with IS without MI, the MI group had a higher National Institute of Health Stroke Scale score after onset (4.0 versus 3.0; Hodges‐Lehmann estimator, 22.5) and a higher proportion of severe strokes (National Institute of Health Stroke Scale score ≥15) (7.1% versus 4.4%; absolute standardized difference=11.6%). In the fully adjusted models, the risk of in‐hospital mortality was higher in the MI group (odds ratio [OR], 1.74; 95% CI, 1.57–1.92; P P P P P P P P Conclusions Patients with IS with a medical history of MI have an increased risk of severe stroke, in‐hospital mortality, and complications. Studies exploring the underlying mechanisms are needed to improve and tailor stroke treatment strategies.

Background Intracerebral hemorrhage (ICH) has a high mortality and morbidity in the world. C-Reaction Protein (CRP) has been demonstrated to be an independent risk factor and could predict the severity and outcome of ischemic stroke. In our study, we aimed to find out the relationship between CRP levels and the severity and outcome of patients with ICH. Methods This study comes from the Chinese Stroke Center Alliance (CSCA). Patients' basic characteristics and laboratory examination results, including the concentration of CRP were taken from August 2015 to July 2019. Chi-square test and Logistic regression were used to analyze the relationship between different CRP levels and clinical outcome. Results A total of 9589 patients with acute ICH were enrolled in our study. In the logistic regression analysis, we found out that high CRP level is an independent risk factor for the prevalence of severe ICH and in-hospital death. After adjusting sex, age and other relevant stroke risk factors, the difference still exists (Severe ICH: odd ratio (OR) (95% confidence interval (CI) = 1.14 (1.04-1.26), P = 0.0076 for CRP between 3-10mg/l group and 1.64 (1.46-1.84), P 10mg/l group. In-hospital death: OR(95%CI)= 2.03(1.39-2.95), P=0.0002 for CRP>10mg/l group). Conclusions High CRP level was independently associated with poorer clinical outcome and higher in-hospital death in patients with ICH.

Background The influence of chronic kidney disease (CKD) on the severity and prognosis of spontaneous intracerebral hemorrhage (ICH) has been scarcely investigated. We aimed to explore the association of admission estimated glomerular filtration rate (eGFR) levels with hemorrhagic stroke severity and outcomes in ICH patients. Materials and methods The patients enrolled in this study were from the China Stroke Center Alliance study (CSCA). Patients were divided into four groups according to differences in eGFR at admission (≥90; 60–89; 45–59; Results A total of 85,167 patients with acute ICH were included in the analysis. Among them, 9493 (11.1%) had a baseline eGFR2. A low eGFR was associated with an increased risk of in-hospital mortality [eGFR 60–89 ml/min/1.73 m2, odds ratio (OR) 1.36 (95% confidence interval (CI) 1.21–1.53); eGFR 45–59, 2.35 (1.97–2.82); eGFRP for trend P for trend P for trend P for trend P for trend = 0.0139] after adjusting for confounding factors. With the decline in eGFR, the risk of hematoma evacuation increased in patients with an eGFR 45 to 59 ml/min/1.73 m2 (OR 1.48; 95% CI 1.37–1.61). No significant association between differences in eGFR at baseline and in-hospital complication of recurrent intracerebral hemorrhage was observed. Conclusions Low eGFR at baseline was associated with an increased risk of in-hospital mortality, non-routine discharge, hemorrhagic stroke severity and in-hospital complications such as pneumonia, hydrocephalus and hematoma evacuation in acute ICH patients.

Background Previous assessments of sex differences for patients with acute ischemic stroke were limited in a specific region or population, narrow scope, or small sample size. Methods Patients with acute ischemic stroke hospitalized in the China Stroke Center Alliance hospitals were analyzed. Absolute standardized differences (ASDs) were used to assess sex differences in vascular risk factors, guideline-recommended in-hospital management measures and outcomes, including stroke severity (National Institutes of Health Stroke Scale≥16), death/discharge against medical advice, major adverse cardiovascular events, pneumonia, and disability (modified Rankin Scale≥3). Results Of 838,229 patients analyzed, 524351 (62.6%) were men and 313,878 (37.4%) were women. Compared with men, women were older (68.6 vs. 64.7 years), had higher prevalence of hypertension (67.7% vs. 62.4%), diabetes (24.7% vs. 19.5%), and atrial fibrillation (7.1% vs. 4.3%), but lower prevalence of smoking (4.5% vs. 56.6%) and drinking (2.6% vs 35.8%) (ASDs >10%). No sex differences were seen in guideline-directed management measures, indicated by risk-adjusted individual measures and the all-or-null summary measure (34.5% vs 34.9%, ASD = 1.0%). Compared to men, women tended to have strokes that were more severe at presentation (6.5% vs. 4.5%, ASD = 8.8%) and more disabilities at discharge (34.9% vs 30.5%, ASD =9.4%). However, all sex-related differences in outcomes were attenuated to null after risk adjustments (ASDs Conclusions Compared to male patients, female patients had more vascular risk factors and received similar in-hospital care. They had strokes that were more severe at presentation and more disabilities at discharge, both of which may be explained by worse vascular risk profiles.

Background Postoperative delirium (POD) has been confirmed as an important complication after major surgery. However, neurosurgical patients have usually been excluded in previous studies. To date, data on POD and risk factors in patients after intracranial surgery are scarce. Objectives To determine the incidence and risk factors of POD in patients after intracranial surgery. Design Prospective cohort study. Setting A neurosurgical ICU of a university-affiliated hospital, Beijing, China. Interventions Adult patients admitted to the ICU after elective intracranial surgery under general anaesthesia were consecutively enrolled between 1 March 2017 and 2 February 2018. Delirium was assessed using the Confusion Assessment Method for the ICU. POD was diagnosed as Confusion Assessment Method for the ICU positive on either postoperative day 1 or day 3. Patients were classified into groups with or without POD. Data were collected for univariate and multivariate analyses to determine the risk factors for POD. Results A total of 800 patients were included. POD was diagnosed in 157 patients (19.6%, 95% confidence interval 16.9 to 22.4%). Independent risk factors for POD included age, nature of intracranial lesion, frontal approach craniotomy, duration of surgery, presence of an episode of low pulse oxygenation at ICU admission, presence of inadequate emergence and emergence delirium, postoperative pain and presence of immobilising events. POD was associated with adverse outcomes and high costs. Conclusion POD is prevalent in patients after elective intracranial surgery. The identified risk factors for and the potential association of POD with adverse outcomes suggest that a comprehensive strategy involving screening for predisposing factors and early prevention of modifiable factors should be established in this population. Trial registration ClinicalTrials.gov NCT03087838.

AimSpontaneous subarachnoid haemorrhage (SAH) caused by ruptured cerebral aneurysm is a severe subtype of haemorrhagic stroke. Although the incidence of SAH is relatively low among all cerebrovascular diseases, the mortality is the highest. The critical management of SAH is challenging. We provide this evidence-based guideline to present current and comprehensive recommendations for the diagnosis and treatment of non-trauma SAH.MethodsA formal literature search of MEDLINE (1 January 1990–30 June 2019) was performed. Data were synthesised with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The Chinese Stroke Association’s levels of evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by Chinese Stroke Association’s Stroke Fellow Committees. It is intended that this guideline be fully updated every 3 years.ResultsEvidence-based guidelines are presented for the care of patients presenting with non-trauma SAH. The focus of the guideline was subdivided into transfer and systems of care, diagnosis flowchart, aetiology and differentiation, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, management of vasospasm and delayed cerebral ischaemia, management of hydrocephalus, management of seizures and management of medical complications.ConclusionsThe guideline offers a framework for SAH management. Early professional and aggressive care of SAH might help dramatically.

Our study aimed to explore changes in health-related quality of life (HRQoL) during blood pressure control and blood lipid-lowering therapies. We conducted a 2 × 2 factorial-designed randomized controlled trial in 180 clinical centers in China. At baseline, participants were randomly assigned to an amlodipine + amiloride/hydrochlorothiazide group or an amlodipine + telmisartan group for the blood pressure control treatment and to a statin group or a routine intervention group for the blood lipid-lowering treatment. The allocation ratio was 1:1 for both treatments. Follow-up lasted for 4 years. HRQoL was assessed using the EuroQol five dimensions three levels (EQ-5D-3L) questionnaire every year. Of 13,542 hypertensive patients enrolled in the clinical trial, 9885 were eligible for the analysis. The problems for all dimensions of the EQ-5D-3L descriptive system were slight at baseline and were well preserved in the follow-up period. The EuroQol visual analog scale (EQ VAS) score and the EQ-5D-3L index improved over time (Ptrend

Background and Purpose— Emergency medical services (EMSs) are critical for early treatment of patients with ischemic stroke, yet data on EMS utilization and its association with timely treatment in China are still limited. Methods— We examined data from the Chinese Stroke Center Alliance for patients with ischemic stroke from June 2015 to June 2018. Absolute standardized difference was used for covariates’ balance assessments. We used multivariable logistic models with the generalized estimating equations to account for intrahospital clustering in identifying demographic and clinical factors associated with EMS use as well as in evaluating the association of EMS use with timely treatment. Results— Of the 560 447 patients with ischemic stroke analyzed, only 69 841 (12.5%) were transported by EMS. Multivariable-adjusted results indicated that those with younger age, lower levels of education, less insurance coverage, lower income, lower stroke severity, hypertension, diabetes mellitus, and peripheral vascular disease were less likely to use EMS. However, a history of cardiovascular diseases was associated with increased EMS usage. Compared with self-transport, EMS transport was associated with significantly shorter onset-to-door time, door-to-needle time (if prenotification was sent), earlier arrival (adjusted odds ratio [95% CIs] were 2.07 [1.95–2.20] for onset-to-door time ≤2 hours, 2.32 [2.18–2.47] for onset-to-door time ≤3.5 hours), and more rapid treatment (2.96 [2.88–3.05] for IV-tPA [intravenous recombinant tissue-type plasminogen activator] in eligible patients, 1.70 [1.62–1.77] for treatment with IV-tPA by 3 hours if onset-to-door time ≤2 hours, and 1.76 [1.70–1.83] for treatment with IV-tPA by 4.5 hours if onset-to-door time ≤3.5 hours). Conclusions— Although EMS transportation is associated with substantial reductions in prehospital delay and improved likelihood of early arrival and timely treatment, rate of utilization is currently low among Chinese patients with ischemic stroke. Developing an efficient EMS system and promoting culture-adapted education efforts are necessary for improving EMS activation.

BACKGROUND Intravenous and inhalational anesthesia might have different associations with long-term outcome in cancer patients, with reports of adverse effects of inhalation anesthesia. However, the effects of anesthesia in patients with high-grade glioma (HGG) are not known. METHODS This study investigated 154 patients who received propofol and 140 patients who received sevoflurane for maintenance of anesthesia during HGG tumor resection. The primary outcomes were progression-free survival and overall survival. RESULTS Median progression-free survival was 10 months (interquartile range [IQR], 6 to 18) versus 11 months (IQR 6 to 20; P=0.674), and median overall survival was 18 months (IQR, 11 to 39) versus 18 months (IQR, 10 to 44; P=0.759) in patients maintained with propofol and sevoflurane, respectively. Higher preoperative Karnofsky performance status and postoperative chemotherapy were associated with a reduced hazard of tumor progression or death, whereas higher age-adjusted Charlson comorbidity index and longer duration of anesthesia were associated with an increased hazard of progression or death. World Health Organization tumor classification IV and incomplete tumor resection were associated with an increased hazard of tumor progression but not death. Anesthesia maintenance with sevoflurane increased the risk of death in patients with Karnofsky performance status

Key Points Question Do prescribers in China follow established guidelines for prescription of oral anticoagulants (OACs) to patients with ischemic stroke and atrial fibrillation, and has adherence to prescribing guidelines changed over time? Findings In this multicenter quality improvement study, among 35 767 eligible patients with ischemic stroke and atrial fibrillation at admission, fewer than 1 in 5 were taking OACs at admission, and of 49 531 eligible patients at discharge, only 41% were prescribed OACs at discharge. Although adherence to OACs has significantly improved over time, it remains suboptimal; the increase was mainly associated with warfarin, not non–vitamin K antagonist OACs. Meaning This study suggests that more specific programs educating physicians and patients are needed to ensure that OACs, especially non–vitamin K OACs, are prescribed to eligible patients., Importance Adherence to oral anticoagulants (OACs) per guideline recommendations is crucial in reducing ischemic stroke and systemic thromboembolism in high-risk patients with ischemic stroke and atrial fibrillation. However, data on OAC use are underreported in China. Objective To assess adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association’s clinical management guideline–recommended prescription of OACs, the temporal improvement in adherence, and the risk factors associated with OAC prescriptions. Design, Setting, and Participants This quality improvement study was conducted at 1430 participating hospitals in the Chinese Stroke Center Alliance (CSCA) among patients with ischemic stroke and atrial fibrillation enrolled in the CSCA between August 1, 2015, and July 31, 2019. Exposure Calendar year. Main Outcomes and Measures Adherence to the Chinese Stroke Association or the American Heart Association/American Stroke Association’s clinical management guideline–recommended prescribing of OACs (warfarin and non–vitamin K OACs, including dabigatran, rivaroxaban, apixaban, and edoxaban) at discharge. Results Among 35 767 patients (18 785 women [52.5%]; mean [SD] age, 75.5 [9.2] years) with previous atrial fibrillation at admission, the median CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]–vascular disease, and sex category [female]) score was 4.0 (interquartile range, 3.0-5.0); 6303 (17.6%) were taking OACs prior to hospitalization for stroke, a rate that increased from 14.3% (20 of 140) in the third quarter of 2015 to 21.1% (118 of 560) in the third quarter of 2019 (P, This quality improvement study assesses adherence to guideline-recommended oral anticoagulants, the temporal improvement in adherence, and the risk factors associated with oral anticoagulant prescriptions.

BACKGROUND: Abnormal electrolytes were closely related to the prognosis of various diseases, the prognostic role of electrolytes in stroke has not been investigated well. We aimed to investigate the association between electrolytes and clinical outcomes in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). METHODS: Data were recruited from the China National Stroke Registry III study. Patients were classified into three groups according to tertiles and the normal range of each electrolyte. Multivariable logistic and Cox proportional hazards regressions were adopted to explore the associations of electrolytes with poor functional outcomes [modified Rankin Scale (mRS) 3–6/2–6] and all-cause death at 3 months and 1 year. RESULTS: A total of 10,299 eligible patients were enrolled. After adjusted for confounding factors, the first tertile electrolytes were associated with increased risk of poor functional outcome (mRS score 3–6) at 1 year, the adjusted odds ratios (95% confidence intervals) were 1.33 (1.14–1.55) for potassium, 1.41 (1.20–1.60) for sodium, 1.27 (1.08–1.48) for chloride, compared with the second tertile. Similar results were found when poor functional outcome was defined as mRS score 2–6 and all-cause death. However, almost no significant association was present of calcium with these outcomes. All results were consistent when each electrolyte was classified into three groups according to the normal range and the outcomes timepoint was set at 3 months. CONCLUSIONS: Lower levels of potassium, sodium, chloride but not calcium were associated with higher risk of poor functional outcomes and death in patients with AIS or TIA.

Background Clinical trials have shown that dexmedetomidine might decrease the occurrence of postoperative delirium after major surgery, but neurosurgical patients were excluded from these studies. We aimed to determine the feasibility of conducting a full-scale randomized controlled trial of the effect of prophylactic low-dose dexmedetomidine on postoperative delirium in patients after elective intracranial operation for brain tumors. Methods In this single-center, parallel-arm pilot randomized controlled trial, adult patients who underwent an elective intracranial operation for brain tumors were recruited. Dexmedetomidine (0.1 μg/kg/hour) or placebo was continuously infused from intensive care unit (ICU) admission on the day of surgery until 08:00 AM on postoperative day one. Adverse events during the study-drug administration were recorded. The primary feasibility endpoint was the occurrence of study-drug interruption. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU during the first five postoperative days. The assessable rate of delirium evaluation was documented. Results Sixty participants were randomly assigned to receive either dexmedetomidine (n = 30) or placebo (n = 30). The study-drug was stopped in two patients (6.7%) in the placebo group due to desaturation after new-onset unconsciousness and an unplanned reoperation for hematoma evacuation and in one patient (3.3%) in the dexmedetomidine group due to unplanned discharge from the ICU. The absolute difference (95% confidence interval) of study-drug interruption between the two groups was 3.3% (− 18.6 to 12.0%), with a noninferiority P value of 0.009. During the study-drug infusion, no bradycardia occurred, and hypotension occurred in one patient (3.3%) in the dexmedetomidine group. Dexmedetomidine tended to decrease the incidence of tachycardia (10.0% vs. 23.3%) and hypertension (3.3% vs. 23.3%). Respiratory depression, desaturation, and unconsciousness occurred in the same patient with study-drug interruption in the placebo group (3.3%). Delirium was evaluated 600 times, of which 590 (98.3%) attempts were assessable except in one patient in the placebo group who remained in a coma after an unplanned reoperation. Conclusions The low rate of study-drug interruption and high assessable rate of delirium evaluation supported a fully powered trial to determine the effectiveness of low-dose dexmedetomidine on postoperative delirium in patients after intracranial operation for brain tumors. Trial registration The trial was registered at ClinicalTrials.gov (NCT04494828) on 31/07/2020.

Background: The relationship between glycosylated hemoglobin (HbA1c) and prognosis of spontaneous intracerebral hemorrhage (SICH) patients has not been fully elucidated. This study aimed to reveal the relationship between HbA1c levels and short-term mortality after patient admission with SICH.Methods: It was a large-scale, multicenter, cross-sectional study. From August 1, 2015, to July 31, 2019, a total of 41910 SICH patients were included in the study from the Chinese Stroke Center Alliance (CSCA) program. Finally, we comprehensively analyzed the data from 21,116 patients with SICH. HbA1c was categorized into four groups by quartile. Univariate and multivariate logistic regression analyses were used to assess the association between HbA1c levels and short-term mortality in SICH patients.Results: The average age of the 21,116 patients was 62.8 ± 13.2 years; 13,052 (61.8%) of them were male, and 507 (2.4%) of them died. Compared to the higher three quartiles of HbA1c, the lowest quartile (≤5.10%) had higher short-term mortality. In subgroup analysis with or without diabetes mellitus (DM) patients, the mortality of the Q3 group at 5.60–6.10% was significantly lower than that of the Q1 group at ≤5.10%. After adjustment for potential influencing factors, the ROC curve of HbA1c can better predict the short-term mortality of patients with SICH (AUC = 0.6286 P < 0.001).Conclusions: Therefore, we concluded that low or extremely low HbA1c levels (≤5.10%) after stroke were associated with higher short-term mortality in SICH patients, with or without DM.

Background: Late recovery in patients following prolonged coma from carbon monoxide poisoning have been reported, but the probability is unclear. The purpose of this research was to assess the prognosis of patients in prolonged coma after severe carbon monoxide poisoning and related clinical and imaging features. Methods: There were 13 patients who had been in a state of coma for >7 days after acute carbon monoxide poisoning in the retrospective observational study, and demographic data, clinical data, laboratory data, complications, and image data were collected. Outcome was assessed by means of the Glasgow outcome scale after 1 year. The relationship between complications and imaging manifestations and prognosis was also analyzed. Results: One year after severe carbon monoxide poisoning, two patients (15.4%) had died (GOS 1), nine (69.2%) were in a persistent vegetative state (GOS 2), one (7.7%) was moderately disabled (GOS 4), and one (7.7%) achieved a good recovery (GOS 5) with minimal disability. Conclusions: Most patients with prolonged coma after severe carbon monoxide poisoning had a poor prognosis, although the younger patients had a better prognosis. Respiratory failure, hypotension and renal failure during the course of the disease were associated with a poor prognosis. The prognosis of patients with injuries in two sites in early CT was poor. Multiple lesions (≥3) and extensive white matter damage (Fazekas grade (PVH or DWMH) = 3) on MRI of chronic phase were also associated with a poor prognosis.

Background: It is unclear the impact of the COVID-19 pandemic on the health care and outcomes for in-hospital patients with acute ischemic stroke (AIS). We aimed to evaluate the influence of COVID-19 on the quality of care for in-hospital patients with AIS. Methods: This is an observational registry study between November 23rd, 2019 and March 22nd, 2020. 408 hospital from 29 provinces in China were enrolled from Chinese Stroke Center Alliance (CSCA). Patients with AIS were extracted with demographic, clinical and previous history information. We focus on the time period before and after January 23rd, 2020, when the public health interventions were carried out in China. The primary outcome was adherence to 11 performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to. Secondary outcomes included were time measures and in-hospital outcomes. Results: 42056 patients with AIS was enrolled (mean age 66.5±12.1, male 61.3%). The overall in-hospital patients decreased slightly from 14323 to 14204 before the COVID-19 outbreak and went down sharply by 31.4% and 61.1% after the outbreak and the public conducted interventions in China. A remarkable reduction was shown in patients with NIHSS score ≤ 3 from 57.7% to 55.7% after the outbreak (p Conclusions: The admission number of patients with AIS declined significantly after the COVID-19 outbreak, but the quality of care and outcomes kept stable. Hospitals should admit AIS patients to the fullest extent of ability and provide tailored treatment strategies under the premise of no the cross-infection of COVID-19.

Background and Purpose: A variety of definitions for minor stroke have been proposed. We aimed to compare the clinical characteristics and outcomes of minor stroke defined as the National Institutes of Health Stroke Scale (NIHSS) score ≤5 versus ≤3. Methods: We retrieved acute ischemic stroke patients with NIHSS score ≤5 in the CSCA study (China Stroke Center Alliance) between August 2015 and 2019. In-hospital clinical outcomes including all-cause mortality, stroke, and myocardial infarction were compared between the NIHSS score ≤5 and NIHSS score ≤3 groups using absolute standardized differences (ASD). Results: A total of 1 006 798 patients were registered in the CSCA program from 1476 hospitals, 472 352 patients had NIHSS score ≤5, of whom 356 314 patients had NIHSS score ≤3. The in-hospital composite events of death, myocardial infarction, or recurrent stroke were not significantly different between the NIHSS score ≤5 and NIHSS score ≤3 groups (5.6% [26 346/472 352] versus 5.2% [18 682/356 314]; ASD, 1.8). The in-hospital all-cause mortality (0.1% [443/472 352] versus 0.1% [255/356 314]; ASD, Conclusions: Our large-scale study identified that minor stroke using NIHSS scores ≤5 and ≤3 as the definition was comparable with each other regarding in-hospital all-cause mortality, recurrent stroke, and hemorrhagic stroke. This observation may be useful for future comparison studies and clinical trial design.

Background and Purpose: Our aim was to investigate the frequency of dehydration at admission and associations with in-hospital mortality in patients with intracerebral hemorrhage (ICH).Methods: Data of consecutive patients with ICH between August 2015 and July 2019 from the China Stroke Center Alliance (CSCA) registry were analyzed. The patients were stratified based on the blood urea nitrogen (BUN) to creatinine (CR) ratio (BUN/CR) on admission into dehydrated (BUN/CR ≥ 15) or non-dehydrated (BUN/CR < 15) groups. Data were analyzed with multivariate logistic regression models to investigate admission dehydration status and the risks of death at hospital.Results: A total number of 84,043 patients with ICH were included in the study. The median age of patients on admission was 63.0 years, and 37.5% of them were women. Based on the baseline BUN/CR, 59,153 (70.4%) patients were classified into dehydration group. Patients with admission dehydration (BUN/CR ≥ 15) had 13% lower risks of in-hospital mortality than those without dehydration (BUN/CR < 15, adjusted OR = 0.87, 95%CI 0.78–0.96). In patients aged p = 0.0049) than non-dehydrated patients.Conclusion: Admission dehydration is associated with significantly lower in-hospital mortality after ICH, in particular, in patients

Background and Purpose: The effect of uric acid (UA) levels on severity and prognosis of spontaneous intracerebral hemorrhage (ICH) remains controversial. We aimed to explore the association of admission UA levels with stroke severity and outcomes in ICH patients.Materials and Methods: The patients enrolled in this study were from the China Stroke Center Alliance study (CSCA). Patients were divided into four groups (Q1–Q4) according to the quartiles of UA levels at admission. The primary outcome was in-hospital mortality. The secondary outcomes included stroke severity, in-hospital complications, and discharge disposition. Multivariate logistic regression was adopted to explore the association of UA levels with outcomes after ICH.Results: Patients (84,304) with acute ICH were included in the final analysis; the median (interquartile range) of UA was 277 (210, 354) μmol/L. The four groups were defined as follows: Q1 ≤ 210 μmol/L, 210 μmol/L < Q2 ≤ 277 μmol/L, 277 μmol/L < Q3 ≤ 354 μmol/L, Q4 > 354 μmol/L. There was no significant evidence indicating that UA levels were correlated with the discharge disposition and in-hospital mortality after ICH. However, compared to Q1, the patients with higher UA levels had decreased odds of severe stroke (NIHSS ≥ 16) at admission (OR 0.89, 95% CI 0.86–0.92). An L-shaped association was found between UA and severe stroke. Among in-hospital complications, decrease in pneumonia, poor swallow function, gastrointestinal bleeding, and deep vein thrombosis (DVT) were significantly associated with higher UA levels compared to Q1 (P for trend < 0.0001).Conclusions: UA was a protective factor for stroke severity and in-hospital complications such as pneumonia, poor swallow function, gastrointestinal bleeding, and DVT. However, no significant evidence indicated that UA levels were predictive of the discharge disposition and in-hospital mortality after ICH.

IntroductionPostoperative delirium (POD) is prevalent in patients after major surgery and is associated with adverse outcomes. Several studies have reported that dexmedetomidine, a highly selective α2-adrenergic receptor agonist, can decrease the incidence of POD. However, neurosurgical patients are usually excluded from previous studies. The present study was designed to investigate the impact of prophylactic use of low-dose dexmedetomidine on the incidence of POD in patients after intracranial operation.Methods and analysisThis is a multicentre, randomised, double-blinded and placebo-controlled trial. Seven hundred intensive care unit admitted patients after elective intracranial operation for brain tumours under general anaesthesia are randomly assigned to the dexmedetomidine group or the placebo group with a 1:1 ratio. For patients in the dexmedetomidine group, a continuous infusion of dexmedetomidine will be started at a rate of 0.1 μg/kg/hour immediately after enrolment on the day of operation and continued until 08:00 on postoperative day 1. For patients in the placebo group, normal saline will be administered at the same rate as in the dexmedetomidine group. The patients will be followed up for 28 days after enrolment. The primary endpoint is the incidence of POD, which is assessed two times per day using the Confusion Assessment Method for the intensive care unit (ICU), during the first 5 postoperative days. The secondary endpoints include the incidence of dexmedetomidine-related adverse events and non-delirium complications, the length of stay in the ICU and hospital and all-cause 28-day mortality after the operation.Ethics and disseminationThe study protocol was approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (No KY2019-091-02) and registered at ClinicalTrials.gov. The results of the trial will be presented at national and international conferences relevant to subject fields and submitted to international peer-reviewed journals.Trial registration numberTrial registration number: NCT04399343; Pre-results.

Background: Neuromyelitis Optica Spectrum Disorder (NMOSD) is an inflammatory disease of the central nervous system with preferential involvement of the optic nerve and spinal cord. However, data on NMOSD incidences in China, a country encompassing 20% of the world's population and covering vast areas of Eastern Asia, are unknown. Methods: We conducted the first nationwide survey of NMOSD, based on the database of the National Hospital Quality Monitoring System (HQMS) of China, which covers all 1665 tertiary hospitals. The “Medical Record Homepage” of all patients were consistently collected via a standard protocol across each tertiary hospital. The primary outcome was the incidence of NMOSD, diagnosed according to the 2015 International Panel for Neuromyelitis Optica Diagnosis criteria and identified by ICD-10 code (G36•0). Burden of hospitalization, comorbidities, and death were also evaluated. Findings: We identified 33,489 hospital admissions for 17,416 NMOSD diagnosed patients from 2016 to 2018. 11,973 patients were newly diagnosed NMOSD. The age and sex adjusted incidence per 100,000 person years was 0•278 (95% confidence interval [CI], 0•273–0•283), with 0•075 (0•069–0•08) in child and 0•347 (0•34–0•353) in adult. The peak age of onset NMOSD is 45–65 years with an incidence 0•445/100,000 (95% CI, 0•433–0•457). The female to male ratio was 4•71 (p

BackgroundsEmbolic stroke is one of the main mechanisms of ischaemic stroke. Even if treated with recommended antithrombotic agents, stroke recurrence remains high. The Shuxuetong injection, a purified extract of traditional Chinese medicine widely used for thrombus diseases in clinical practice in China, could be a promising agent to prevent stroke recurrence.AimsTo describe the design of the Shuxuetong injection for prevention of recurrence in acute ischaemic stroke with embolism mechanisms.DesignThe Shuxuetong for Prevention of recurrence in Acute Cerebrovascular events with Embolism (SPACE) trial is a multicentre, randomised, double-blind, placebo-controlled, parallel-group, superiority trial to evaluate the efficacy and safety of Shuxuetong injection in reducing recurrence or silent new ischaemic lesions on patients with acute embolic stroke within 10 days. An estimated 2416 patients with embolic stroke within 72 hours of symptom onset from 80 hospitals will be randomly assigned to one of two groups receiving Shuxuetong injection or placebo injection for 10 days. The primary endpoint is symptomatic or asymptomatic new cerebral infarction within 10 days after randomisation.ConclusionThe SPACE Trial will provide valuable evidence for the efficacy and safety of Shuxuetong injection for the prevention of stroke recurrence in patients with imaging-defined embolic stroke.Clinical trial registrationNCT03090113.

Background: Multiple sclerosis (MS) is a leading cause of disability among young adults and effects considerable social and economic burdens. Data of MS incidence in China at the national level is lacking. We conducted the first nationwide hospital-based study to estimate the incidence and hospitalization burden of MS in China. Methods: This study is based on an administrative database of the National Hospital Quality Monitoring System, which covers all 1665 tertiary hospitals in mainland China. The “Medical Record Homepage” of all patients, including 346 variables including demographic characteristics, diagnoses, procedures, and expenses etc., were uniformly collected across each tertiary hospital via standard protocol. MS was defined by the 2010 International Panel criteria for MS and was identified by ICD-10 code (G35•0). Findings: We identified 27,336 hospital admissions for 15,060 MS patients from 2016 to 2018; amongst these patients, 9,879 were newly diagnosed. The age- and sex-adjusted incidence per 100,000 person-years is 0•235 (95% confidence interval [CI] 0•230–0•240), with 0•055 (0•050–0•060) in children and 0•288 (0•282–0•294) in adults, respectively. The female to male ratio is 2•02; the peak disease onset is age of 40–49 years. Residents in high-latitude and high-altitude areas are more likely to develop MS (F = 8•99; p

OBJECTIVE The present study aimed to summarize and update the evidence regarding the association between periodontitis and psoriasis. METHODS The present systematic review was conducted under the guidelines of Transparent Reporting of Systematic Reviews and Meta-Analyses (PRISMA) and was recorded in the PROSPERO database, under registration number CRD42017063799. Three databases (MEDLINE, Embase, and Cochrane Library) were searched up to March 2020. Case-control or cohort studies assessing the association between periodontitis and psoriasis were identified. Quantitative synthesis was conducted with meta-analysis. RESULTS A total of 13 studies (11 case-control and two cohort studies) assessing the association between periodontitis and psoriasis were included. Of these 13 articles, 9 showed the prevalence of periodontitis or psoriasis. Therefore, meta-analyses were conducted with data retrieved from the nine studies included. Pooled effect estimate for nine studies showed that patients with periodontitis associated with a higher risk of psoriasis with a pooled OR of 2.87 (95% CI, 1.75-4.69). CONCLUSIONS This systematic review demonstrated a positive association between periodontitis and psoriasis; however, a causal relationship cannot be established. Due to the weak evidence, caution should be taken when interpreting the results regarding periodontal parameters. Well-designed prospective studies are necessary to evaluate interactions between both diseases.

Background and aimObesity paradox has aroused increasing concern in recent years. However, impact of obesity on outcomes in intracerebral haemorrhage (ICH) remains unclear. This study aimed to evaluate association of body mass index (BMI) with in-hospital mortality, complications and discharge disposition in ICH.MethodsData were from 85 705 ICH enrolled in the China Stroke Center Alliance study. Patients were divided into four groups: underweight, normal weight, overweight and obese according to Asian-Pacific criteria. The primary outcome was in-hospital mortality. The secondary outcomes included non-routine discharge disposition and in-hospital complications. Discharge to graded II or III hospital, community hospital or rehabilitation facilities was considered non-routine disposition. Multivariable logistic regression analysed association of BMI with outcomes.Results82 789 patients with ICH were included in the final analysis. Underweight (OR=2.057, 95% CI 1.193 to 3.550) patients had higher odds of in-hospital mortality than those with normal weight after adjusting for covariates, but no significant difference was observed for patients who were overweight or obese. No significant association was found between BMI and non-disposition. Underweight was associated with increased odds of several complications, including pneumonia (OR 1.343, 95% CI 1.138 to 1.584), poor swallow function (OR 1.351, 95% CI 1.122 to 1.628) and urinary tract infection (OR 1.532, 95% CI 1.064 to 2.204). Moreover, obese patients had higher odds of haematoma expansion (OR 1.326, 95% CI 1.168 to 1.504), deep vein thrombosis (OR 1.506, 95% CI 1.165 to 1.947) and gastrointestinal bleeding (OR 1.257, 95% CI 1.027 to 1.539).ConclusionsIn patients with ICH, being underweight was associated with increased in-hospital mortality. Being underweight and obese can both increased risk of in-hospital complications compared with having normal weight.

Background: Little is known about healthcare quality and patient outcomes of ischemic cerebrovascular diseases between urban and rural areas in China during the past decade. Methods: We used a two-stage random sampling method to create a nationally representative sample of patients in China hospitalized for ischemic stroke (IS)/ Transient ischemic attack (TIA) in 2005, 2010, and 2015. Firstly, we used simple random sampling to obtain a list of participating hospitals in 2 urban and 3 rural strata. Secondly, we obtained medical records at each hospital on clinical profiles, tests, treatments and outcomes using a systematic sampling approach. We weighted our findings to explore rural-urban disparities from 2005 to 2015. Results: A total of 30 827 patients were sampled from 189 hospitals with 14 418 (46.8%) from urban and 16 409 (53.2%) from rural. We observed a decreased disparity between urban and rural in eligible patients receiving antiplatelet and anticoagulant for atrial fibrillation (AF) (both P trend trend trend trend Conclusion: Although urban-rural disparities in evidence-based treatments for IS/TIA patients have largely been eliminated, substantial gaps in quality of care persist in both settings.

Background and Purpose: China has made an impressive achievement in both the scale of coverage and the speed of expansion of its health insurance system, yet data regarding health insurance-related disparities in managements patents and in-hospital outcomes for ischemic stroke/transient ischemic attack (IS/TIA) are still limited. Methods: We used a two-stage random sampling method to create a nationally representative sample of patients in China hospitalized with IS/TIA in 2005, 2010, and 2015. Health insurance was limited in Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI), New Rural Cooperative Medical Scheme (NRCMS), and self-payment. We used three composite measures to summarize the treatment and management for assessment tests, in-hospital treatments, and medication at discharge. In-hospital outcomes, including death, discharge against medical advice (DAMA), and a composite outcome of death or DAMA, were assessed. Results: Of the 23,389 analyzed patients, the percentage of self-payment patients decreased from 56.3% in 2005 to 9.4% in 2015. Composite measures showed no significant difference between insurance status for in-hospital treatments and medication at discharge, except for assessment tests. Compared to UEBMI, other insurance groups had a higher risk of DAMA and in-hospital mortality or DAMA. Nevertheless, the discrepancies become smaller from 2005 to 2015 (P for interaction < 0.0001) (Figure 1). Conclusions: Health insurance-related disparities exist in management patterns and in-hospital outcomes for ischemic cerebrovascular disease, nevertheless, the discrepancies become improved to some degree from 2005 to 2010.

BackgroundIn June 2015, the Chinese Stroke Association (CSA) initiated the Chinese Stroke Center Alliance (CSCA) to establish the national hospital-based stroke care quality assessment and improvement platform. This article outlines its objectives, operational structure, patient population, quality improvement (QI) intervention tools, data elements, data collection methodology and current patient and hospital data.MethodsThe CSCA is a national, hospital-based, multicentre, voluntary, multifaceted intervention and continuous QI initiative. This multifaceted intervention includes stroke centre development, written care protocols, workshops and a monitoring/feedback system of evidence-based performance measures. The data coordinating centre of the CSCA resides at the China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital.ResultsAs of July 2017, 1576 hospitals in China have contributed detailed clinical information to serve as a benchmark for the stroke care quality of 433 264 patients with acute stroke/transient ischaemic attacks (TIA), including 352 572 (81.38%) acute ischaemic stroke, 30 362 (7.01%) TIA, 42 080 (9.71%) spontaneous intracranial haemorrhage, 5505 (1.27%) subarachnoid haemorrhage and 2745 (0.63%) not specified stroke.ConclusionThe CSCA programme is designed to establish a continuous national stroke registry and help healthcare providers develop stroke centres and treat patients in a consistent manner in accordance with accepted national guidelines and, ultimately, improve patient outcomes. It supports the CSA mission to reduce stroke burden in China.

Background and Purpose— The aim of the study was to investigate the utility of iodine contrast agent leakage (the iodine sign) analyzed by Gemstone spectral imaging in early hematoma formation compared with that of the spot sign for predicting early hematoma expansion (HE) and poor functional outcomes. Methods— From 2014 to 2017, 91 patients with spontaneous intracerebral hemorrhage who underwent spectral computed tomography angiography within 6 hours of spontaneous intracerebral hemorrhage onset were prospectively included in our study. We defined a positive iodine sign as tiny enhancing foci within the hematoma on Gemstone spectral imaging and an iodine concentration inside the foci of >7.82 (100 µg/mL). Univariate and multivariate logistical regression analyses were performed to assess risk factors for HE, and the predictive value of HE was analyzed. Results— Positive spot and iodine signs were present in 38.5% (35/91) and 57.1% (52/91) of the patients, respectively. Using multivariate analysis, the iodine sign independently predicted HE (odds ratio, 53.67; 95% CI, 11.88–242.42; P 2 =29.97; P Conclusions— The iodine sign is a reliable and sensitive marker for predicting HE and poor functional outcomes. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02625948.

Objective Prior data suggest paternal or sibling stroke was associated with increased risk of offspring stroke. Whether family history of cardiovascular disease (FHc) predicts risk of stroke recurrence remains unclear, we aim to determine this issue on patients with ischemic stroke (IS) or transient ischemic attack (TIA). Materials and Methods This is a post hoc analysis based on the Third China National Stroke Registry III. IS/TIA patients with data of FHc status were included. FHc was defined as family history of coronary heart disease (CHD) or stroke among first-degree relatives (include parents, children, and siblings (same parents)). Cox proportional hazards regression models were performed to assess the association between FHc and recurrent events at 1 year follow-up. Results Totally 14,208 patients with verified FHc status were included, 4,454 (31.3%) were female and the median (IQR) age was 62.0 (54.0, 70.0) years. Of these, 294 (2.1%), 726 (5.1%) and 1936 (13.6%) had family history of both CHD and stroke, family history of CHD, and family history of stroke only, respectively. Using multivariable Cox models adjusted for age, sex, and vascular risk factors, we found that patients with FHc experienced higher risk of stroke recurrence (HR=1.151, 95%CI=1.000-1.324) and combined vascular events (HR=1.186, 95%CI=1.036-1.358) at 1 year compared with those without FHc. In sensitivity analysis on patients who received primary secondary prevention treatment of antiplatelet and statins, the association persisted. Conclusions FHc is associated with increased risk of stroke recurrence even under primary secondary prevention treatment.

Importance Stroke represents a significant burden on the health care system of China. The Chinese Stroke Center Alliance was launched in 2015 to monitor and improve care quality and outcomes for patients with acute stroke and transient ischemic attack (TIA). Objective To evaluate the clinical characteristics, management, and in-hospital clinical outcomes and complications among patients with stroke or TIA in China. Design, setting, and participants This quality improvement study assessed stroke or TIA admissions to 1476 participating hospitals in the Chinese Stroke Center Alliance between August 1, 2015, and July 31, 2019. Exposures Stroke types and calendar year. Main outcomes and measures Eleven guideline-based admission or discharge management measures and 2 summary measures: an all-or-none binary outcome and a composite score (range, 0 [nonadherence] to 1 [perfect adherence]) for adherence to evidence-based stroke and TIA care and in-hospital clinical outcomes, including death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACEs), including ischemic stroke, hemorrhagic stroke, TIA, or myocardial infarction; and in-hospital complications. Results Of 1 006 798 patients with stroke or TIA (mean [SD] age, 65.7 [12.2] years; 383 500 [38.1%] female), 838 229 (83.3%) had an ischemic stroke, 64 929 (6.4%) had TIA, 85 705 (8.5%) had intracerebral hemorrhage (ICH), and 11 241 (1.1%) had subarachnoid hemorrhage (SAH). Management measures varied by cerebrovascular event type, with the mean (SD) composite score ranging from 0.57 (0.31) in SAH to 0.83 (0.24) in TIA. Poor outcomes and complications were highest among patients with SAH (21.9%; 95% CI, 21.0%-22.8% in-hospital death or DAMA; 9.6%; 95% CI, 9.1%-10.2% MACEs; and 31.4%; 95% CI, 30.6%-32.3% in-hospital complications) and patients with ICH (17.2%; 95% CI, 16.9%-17.5% in-hospital death or DAMA; 9.3%; 95% CI, 9.1%-9.5% MACEs; and 31.3%; 95% CI, 31.0%-31.6% in-hospital complications), followed by patients with ischemic stroke (6.1%; 95% CI, 6.0%-6.1% in-hospital death or DAMA; 6.3%; 95% CI, 6.3%-6.4% MACEs; and 12.8%; 95% CI, 12.7%-12.9% in-hospital complications), and lowest in patients with TIA (5.0%; 95% CI, 4.8%-5.2% in-hospital death or DAMA; 2.4%; 95% CI, 2.3%-2.5% MACEs; and 0.8%; 95% CI, 0.7%-0.8% in-hospital complications). Temporal improvements in management measures were observed from 2015 to 2019, especially in administration of intravenous recombinant tissue plasminogen activator (+60.3% relatively; 95% CI, 52.9%-70.5%), dysphagia screening (+14.7% relatively; 95% CI, 14.0%-15.6%), and use of anticoagulants for atrial fibrillation (+31.4% relatively; 95% CI, 25.7%-37.3%). Temporal improvements in in-hospital death or DAMA (-9.7% relatively; 95% CI, -9.6% to -8.5%) and complications (-27.1% relatively; 95% CI, -28.6% to -25.3) were also observed. Conclusions and relevance In this quality improvement study, performance measure adherence and poor outcomes and complications varied by cerebrovascular event type; although there were substantial improvements over time, these results suggest that support for the use of evidence-based practices is needed.

BACKGROUND: Lowering low-density lipoprotein cholesterol (LDL-C) is crucial for secondary stroke prevention in stroke patients with preexisting cardiovascular diseases (CVD) or cerebrovascular diseases (CeVD). However, data on attainment of guideline-recommended LDL-C levels are lacking. METHODS: We analyzed data from the Chinese Stroke Center Alliance (CSCA) program for patients with ischemic stroke and transient ischemic attack (TIA) hospitalized between August 2015 and July 2019. Participants were classified into different disease groups according to preexisting CeVD (stroke/TIA) or CVD [coronary heart disease (CHD) or myocardial infarction (MI)]. RESULTS: Of 858,509 patients presenting with an acute stroke/TIA, 251,176 (29.3%) had a preexisting CeVD, 44,158 (5.1%) had preexisting CVD, 33,070 (3.9%) had concomitant preexisting CeVD and CVD, and 530,105 (61.7%) had no documented history of CeVD/CVD. Overall, only 397,596 (46.3%) met the target for LDL-C

We aimed to assess the association between systolic blood pressure (SBP) and clinical outcome in 2,397 ischemic stroke (IS) or transient ischemic attack (TIA) patients from the Blood Pressure and Clinical Outcome in TIA or Ischemic Stroke (BOSS) study. BOSS study was a hospital-based, prospective cohort study. The SBP was defined as mean value of 90 days self-measured SBP after onset. Cox proportional hazards models were conducted to test the risk of combined vascular events (CVE) and stroke recurrence among different SBP categories. Restricted cubic splines were used to explore the shape of associations between SBP and clinical outcomes. A J-shaped association of SBP with CVE and stroke recurrence within 90 days was observed (P nonlinearity

Background The impact of estimated glomerular filtration rate ( eGFR ) on clinical short‐term outcomes after stroke thrombolysis with tissue plasminogen activator remains controversial. Methods and Results We analyzed 18 320 ischemic stroke patients who received intravenous tissue plasminogen activator at participating hospitals in the Chinese Stroke Center Alliance between June 2015 and November 2017. Multivariate logistic regression models were used to evaluate associations between eGFR (2 ) and in‐hospital mortality and symptomatic intracerebral hemorrhage, adjusting for patient and hospital characteristics and the hospital clustering effect. Of the 18 320 patients receiving tissue plasminogen activator, 601 (3.3%) had an eGFR eGFR 45 to 59, 3679 (20.1%) had an eGFR 60 to 89, and 13 415 (73.2%) had an eGFR ≥90. As compared with eGFR ≥90, eGFR values CI , 2.18–5.91), 45 to 59 (4.0% versus 0.9%, adjusted odds ratio, 2.00; 95% CI , 1.18–3.38), and 60 to 89 (2.5% versus 0.9%, adjusted odds ratio, 1.67; 95% CI , 1.20–2.34) were independently associated with increased odds of in‐hospital mortality. However, there was no statistically significant association between eGFR and symptomatic intracerebral hemorrhage. Conclusions eGFR was associated with an increased risk of in‐hospital mortality in acute ischemic stroke patients after treatment with tissue plasminogen activator. eGFR is an important predictor of poststroke short‐term death but not of symptomatic intracerebral hemorrhage.

Using data from the Blood Pressure and Clinical Outcome in TIA or Ischemic Stroke (BOSS) study, we aim to test the applicability and feasibility of stroke secondary prevention recommendations from the 2017 American College of Cardiology/American Heart Association guideline. Patients were categorized based on their blood pressure (BP) status at 3 months. The nonhypertension group was defined as those without a diagnosis of hypertension. The other patients were further divided into three subgroups according to office BP measured at 3-month visit (BP

Background and Purpose— We aim to compare the risk of 1-year ischemic stroke recurrence and death for atrial fibrillation diagnosed after stroke (AFDAS), atrial fibrillation known before stroke (KAF), and sinus rhythm (SR). Methods— From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals in the China National Stroke Registry II. Based on heart rhythm assessed during admission, we classified patients as AFDAS, KAF, or SR. We explored the relationship between heart rhythm groups and 1-year ischemic stroke recurrence or death by using Cox regression adjusted for multiple covariates. Considering that death is a competing risk for stroke recurrence, we used the competing risks analysis of Fine and Gray and subdistribution Cox proportional hazards to test the association between heart rhythm and 1-year outcomes. Results— Among 19 604 ischemic stroke patients, 17 727 had SR, 495 AFDAS, and 1382 KAF. At 1 year, 54 (10.9%) patients with AFDAS, 182 (13.2%) with KAF, and 1008 (5.7%) with SR had recurrent ischemic strokes ( P P Conclusions— This study showed that AFDAS had similar risk of 1-year ischemic stroke recurrence and mortality when compared with KAF and higher risk when compared with SR. The potential risk of AFDAS should be given more emphasis, and appropriate treatment is needed to achieve reduction in the incidence of stroke recurrence and mortality.

BackgroundIn 2009, China launched ambitious healthcare reform plans to provide affordable and equitable basic healthcare for all patients, including the substantial number of patients who had a stroke. However, little is known about the pattern of evidence-based stroke care and outcomes across hospitals, regions and time during the last decade.AimsThe Patient-centered Retrospective Observation of Guideline-Recommended Execution for Stroke Sufferers in China (China PROGRESS) Study aims to use findings from a representative sample of Chinese hospitals over the last decade to improve future stroke care for patients hospitalised with ischaemic stroke (IS) or transient ischaemic attack (TIA).DesignThe China PROGRESS Study will use a two-stage cluster sampling method to identify over 32000 patient records from 208 hospitals across the Eastern, Central and Western geographical regions in China. To assess the temporal trends in patient characteristics, treatment and outcomes, study investigators will select records from 2005, 2010 and 2015. A double data reading/entry system will be developed to conduct this assessment. A central coordinating centre will monitor case ascertainment, data abstraction and data management. Analyses will examine patient characteristics, testing patterns, in-hospital treatment and outcomes, and variations across regions and across time.ConclusionsThe China PROGRESS Study is the first nationally representative study that aims to better understand care quality and outcomes for patients with IS or TIA before and after the national healthcare reform in China. This initiative will translate findings into clinical practices that improve care quality for patients who had a stroke and policy recommendations that allow these changes to be implemented widely.Ethics approvalThis study has also been approved by the central institutional review board (IRB) at Beijing Tiantan Hospital.

Background and Objective: Pretreatment with statins has been shown in several studies to be associated with reduced infarct volume and improved functional outcomes after ischemic stroke, but limited data were available specific to atrial fibrillation (AF) related ischemic stroke. The present study investigated the impact of statin use before onset on both initial severity and in-hospital outcomes in ischemic stroke patients with AF. Method: All cases of first-ever ischemic stroke patients with AF were prospectively identified from China Stroke Center Alliances from June 2015 to November 2017. Moderate and severe stroke was defined as National Institutes of Health Stroke Scale score ≥16. In-hospital adverse outcomes included intracerebral hemorrhage, deep vein thrombosis or pulmonary embolism, and pneumonia. We used logistic regression model to estimate propensity score and then we performed inverse probability weighting to assess the association of pre-stroke statin use with moderate and severe stroke and in-hospital adverse outcomes. Results: Among the 18,076 patients included, 1589 (3.9 %) had previously been treated with statins. The risk of moderate and severe stroke was significantly lower in pre-stroke statin users than nonusers (15.3% vs. 18.7%; adjusted odd ratio: 0.85; 95% confidence interval: 0.81-0.90; p Conclusion: Use of statins before first-ever ischemic stroke in patients with AF was associated with reduced stroke severity at admission and decreased risk of adverse outcomes during hospitalization.

Background and Purpose: Emergency medical services (EMSs) is critical for the early treatment of ischemic stroke patients, yet data regarding EMSs utilization and its association with timely treatment are still limited in China. Methods: We examined the data from Chinese Stroke Center Alliance (CSCA) recording consecutive ischemic stroke patients from 2015 June to 2017 November. The absolute standardized difference was used for covariates balance assessments. We used multivariable logistic models to identify factors associated with EMSs usage and to evaluate the effect of EMSs on timely treatment. Results: Of the 326,534 analyzed ischemic patients, only 42,293 (13.0%) were transported by EMSs. Multivariable-adjusted results indicated that younger age, less education, non-urban employ medial insurance, lower income level, less stroke severity, smoking, history of stroke/transient ischemic attack, carotid stenosis, hypertension, diabetes and peripheral vascular disease were associated with decreased risk of EMSs usage. However, coronary heart disease or myocardial infarction, atrial fibrillation and heart failure were associated with increased risk of EMSs usage. Compared to self-transportation, EMS-transported patients were associated with significantly shorter onset-to-door time (Median (IQR): 210 (105-586) vs. 1020 (290-2250) minutes, P Conclusions: EMSs utilization is far from optimal among Chinse ischemic stroke patients. Nevertheless, use of EMSs transportation is associated with substantial reductions in prehospital delay and improved chance of timely treatment. Therefore, community education efforts are needed to improve EMSs activation.

Objective: To compare the risk of 1-year ischemic stroke recurrence and death between atrial fibrillation (AF) diagnosed after stroke (AFDAS), AF known before stroke (KAF) and sinus rhythm (SR). Methods: From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals voluntarily participating in the China National Stroke Registry II. Based on heart rhythm assessed during admission, we classified patients as AFDAS, KAF, or SR. We explored the relationship between heart rhythm groups and 1-year ischemic stroke recurrence and death by using Cox regression adjusted for multiple covariates. Considering death is the competing risk of stroke recurrence, we used the competing-risks analysis of Fine and Gray to assess the association between heart rhythm and stroke recurrence. Results: Among 19604 ischemic stroke patients, 17727 had SR, 495 AFDAS, and 1382 KAF. At 1 year, 54 (10.9%) patients with AFDAS, 182 (13.2%) with KAF, and 1008 (5.7%) with SR had recurrent ischemic strokes (p< 0.0001). The mortality was 22.0% in patients with AFDAS , 22.1% in patients with KAF, and 7.0% in patients with SR (p< 0.0001). AFDAS-related ischemic stroke recurrence adjusted risk was higher than that of SR (hazard ratio 1.48 [95% confidence interval 1.19, 1.85]; p = 0.0005) but not different from that of KAF (hazard ratio 1.09 [95% confidence interval 0.85, 1.40]; p = 0.51). The adjusted risk of 1-year death for AFDAS was also higher than that of SR (hazard ratio 1.60 [95% confidence interval 1.29, 2.00]; p Conclusions: The higher 1-year ischemic stroke recurrence and mortality between AFDAS and SR together with the lack of difference between AFDAS and KAF suggest the similar potential risk of AFDAS.

Background and Purpose: Previous studies have reported the underuse of warfarin for ischemic stroke patients with atrial fibrillation (AF) in China. New oral anticoagulants (NOACs) have become an efficacious alternative to warfarin and been recommended by guidelines. We sought to explore the usage of NOAs and affecting factors in China. Methods: From June 2015 to November 2017, 511 036 patients with acute stroke/TIA were admitted to 1 624 hospitals voluntarily participating in the China Stroke Center Alliance (CSCA), an ongoing, national, hospital-based, multicenter, stroke care quality registry and improvement program. Multivariable logistic regression models using the generalized estimating equation method were used to identify patient/hospital factors independently associated with NOACs use during hospitalization. Results: Among 28 456 ischemic stroke patients with AF, only 798 (2.8%) received NOACs, 8 635 (30.3%) received traditional anticoagulants therapy, 18821 (66.1%) received antiplatelet drugs only. Among patients receiving traditional anticoagulants or NOACs, younger age, lower education level, lower income, rural basic medical insurance schemes, more severity, secondary hospital, Central or West China were associated with lower odds of receiving NOACs (Table 1). Conclusions: Ischemic stroke patients with AF are under treated with anticoagulant, especially with the usage of NOACs. Further efforts are needed to increase the prescription of NOACs and other anticoagulants.