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Original Investigation
September 21, 2020

Trends in Reperfusion Therapy for In-Hospital Ischemic Stroke in the Endovascular Therapy Era

Author Affiliations
  • 1Department of Neurology, Neurosurgery, Emory University Hospital, Atlanta, Georgia
  • 2Duke Clinical Research Institute, Durham, North Carolina
  • 3Department of Neurology, University of Calgary, Calgary, Alberta, Canada
  • 4Brigham and Women’s Hospital Heart & Vascular Center
  • 5Harvard Medical School, Boston, Massachusetts
  • 6Department of Neurology, Duke University, Durham, North Carolina
  • 7Department of Cardiology, University of California, Los Angeles Medical Center, Los Angeles
  • 8Department of Neurology, Massachusetts General Hospital, Boston
JAMA Neurol. 2020;77(12):1486-1495. doi:10.1001/jamaneurol.2020.3362
Key Points

Question  How has reperfusion therapy for in-hospital onset of ischemic stroke changed in the endovascular era?

Findings  This cohort study of 2 237 793 patients found that in-hospital stroke onset was increasingly reported. Endovascular therapy use steadily increased after 2015, whereas the rate of intravenous thrombolysis use doubled since 2008; however, patients with in-hospital stroke onset underwent intravenous thrombolysis and endovascular therapies at significantly slower rates with worse functional outcomes than those with out-of-hospital onset.

Meaning  Although patients with in-hospital stroke onset were increasingly reported and treated with reperfusion therapy, disparities in care persisted, highlighting opportunities to further care for these patients, including the use of dedicated inpatient stroke protocols to bridge this disparity in stroke care.


Importance  A significant proportion of acute ischemic strokes occur while patients are hospitalized. Limited contemporary data exist on the utilization rates of intravenous thrombolysis or endovascular therapy for in-hospital stroke.

Objective  To use a national registry to examine temporal trends in the use of intravenous and endovascular reperfusion therapies for treatment of in-hospital stroke.

Design, Setting, and Participants  This retrospective cohort study analyzed data from 267 956 patients who underwent reperfusion therapy for stroke with in-hospital or out-of-hospital onset reported in the Get With the Guidelines-Stroke national registry from January 2008 to September 2018.

Exposures  In-hospital onset vs out-of-hospital onset of stroke symptoms.

Main Outcomes and Measures  Temporal trends in the use of reperfusion therapy, process measures of quality, and the association between functional outcomes and key patient characteristics, comorbidities, and treatments.

Results  Of 67 493 patients with in-hospital stroke onset, this study observed increased rates of vascular risk factors (standardized mean difference >10%) but no significant differences in age or sex in patients undergoing intravenous thrombolysis only (mean [interquartile range {IQR}] age, 72 [80-62] y; 53.2% female) or those undergoing endovascular therapy (mean [IQR] age, 69 [59-79] y; 49.8% female). Of these patients, 10 481 (15.5%) received intravenous thrombolysis and 2494 (3.7%) underwent endovascular therapy. Compared with 2008, in 2018 the proportion of in-hospital stroke among all stroke hospital discharges was higher (3.5% vs 2.7%; P < .001), as was use of intravenous thrombolysis (19.1% vs 9.1%; P < .001) and endovascular therapy (6.4% vs 2.5%; P < .001) in patients with in-hospital stroke, with a significant increase in endovascular therapy in mid-2015 (P < .001). Compared with patients who received intravenous thrombolysis for out-of-hospital stroke onset, those with in-hospital onset were associated with longer median (IQR) times from stroke recognition to cranial imaging (33 [18-60] vs 16 [9-26] minutes; P < .001) and to thrombolysis bolus (81 [52-125] vs 60 [45-84] minutes; P < .001). In adjusted analyses, patients with in-hospital stroke onset who were treated with intravenous thrombolysis were less likely to ambulate independently at discharge (adjusted odds ratio, 0.78; 95% CI, 0.74-0.82; P < .001) and were more likely to die or to be discharged to hospice (adjusted odds ratio, 1.39; 95% CI, 1.29-1.50; P < .001) than patients with out-of-hospital onset who also received intravenous thrombolysis treatment. Comparisons among patients treated with endovascular therapy yielded similar findings.

Conclusions and Relevance  In this cohort study, in-hospital stroke onset was increasingly reported and treated with reperfusion therapy. Compared with out-of-hospital stroke onset, in-hospital onset was associated with longer delays to reperfusion and worse functional outcomes, highlighting opportunities to further care for patients with in-hospital stroke onset.

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