Introduction:
Acute ischemic stroke (AIS) presents an ongoing challenge for population health and availability of healthcare resources. Imaging plays a critical role in both diagnosis and treatment decisions in AIS, but optimal utilization regarding advanced imaging with angiography and perfusion using either CTAP or MRAP remain uncertain according to national guidelines. Consequently, wide variation in AIS imaging exists in clinical practice, mostly defaulted to physician preferences and institutional factors, without a clear understanding of the benefits and risks involved in stroke care. Although CTAP and MRAP each have unique benefits and risks in the AIS setting, the effect of this risk-benefit tradeoff on health outcomes and utilization of resources is unknown. This study analyses the factors associated with imaging preferences and the related health outcomes.
Method:
We performed a retrospective study on an AIS registry consisting of consecutive patients admitted to our institution from November 1, 2011, through October 1, 2018. Imaging and treatment selections and modified Rankin Score (mRS) at discharge were the main outcomes. Independent variables include age, gender, race-ethnicity, and NIH stroke score (NIHSS) at admission. Multivariable logistic regression models were performed. P<0.05 was considered statistically significant.
Results:
1884 patients with curated imaging data during hospitalization were included. Among them, 32% were ≥80 years old, 47.4% female, 15.53% black, 60.3% white, and 24.4% with NIHSS≥10 at admission. CTAP and MRAP were performed in 21.1% and 72.2% patients, respectively. 46.1% received thrombolytics (IV-tPA), 1.3% had endovascular therapy (EVT), and 52.7% were not treated. The two clinical outcomes were independent functionality at discharge (mRS0-2) at 48.4%, and patients expired in hospital at 7.1%.
Adjusted by all the factors, regression models showed that patients with NIHSS≥10 were more likely to receive CTAP (p<0.0001, OR=3.39) and less likely to receive MRAP (p<0.0001, OR=0.48); whereas age ≥80 was less likely to receive CTAP (p<0.0001, OR=0.37) or MRAP (p<0.0001, OR=0.37). NIHSS≥10 (p<0.0001, OR=0.15) and IV-tPA (p=0.0006, OR=0.69) were negatively related to independent functionality at discharge, and MRAP (p<0.0001, OR=1.97) was positively related to it. NIHSS≥10 (p=0.0212, OR=1.69) were positively related to mortality, while utilization of MRAP showed a negative relationship (p<0.0001, OR=0.26) with it.
Conclusion:
Higher NIHSS was positively associated with mortality and utilization of CTAP, while it is negatively associated with MRAP. MRAP was positively related to independent functionality at discharge. Older age was negatively associated with CTAP or MRAP utilization.