Strokes that happen in the hospital aren’t evaluated and treated as quickly as strokes that happen in the community, new research from Canada confirms.

“These results add to the growing body of evidence in favor of the development of a standardized approach to the recognition and management of in-hospital stroke. In particular, we advocate for the development of targeted code stroke protocols for the in-hospital stroke population, similar to those used in the emergency department,” Moira Kapral, MD, MSc, from Toronto General Hospital and Institute for Clinical Evaluative Sciences, and colleagues write in JAMA Neurology online May 4.

This study confirms that “evolution must continue in the use of code stroke, not only for patients with stroke discovered at the hospital door but also for those within and hiding in plain sight,” Douglas Dulli, MD, MS, of the University of Wisconsin School of Medicine in Madison, notes in a linked editorial.

Using data from the Ontario Stroke Registry, the researchers evaluated the care and outcomes of 973 patients who suffered a stroke while already hospitalized for another reason and about 28,800 with community-onset stroke.

Patients with in-hospital stroke waited significantly longer from symptom recognition to brain imaging (median, 4.5 vs 1.2 hours; p<0.001), with a significantly lower percentage having neuroimaging within two hours of symptom onset (32 percent vs 63 percent for community-onset stroke).

“That’s important because we know that prompt brain imaging is required for interventions like thrombolysis,” Dr. Kapral said in a JAMA Neurology podcast.

Patients with in-hospital stroke were less apt to receive thrombolytic therapy for ischemic stroke (12 percent vs 19 percent; p<0.001) and took longer to receive thrombolysis (median, 2.0 vs 1.2 hours; p<0.001). Fewer in-hospital patients received thrombolysis within 90 minutes of diagnosis (29 percent vs 72 percent of community-onset stroke patients; p<0.001). These differences remained significant after adjusting for age, sex, comorbid conditions, stroke type, and severity.

Patients with in-hospital stroke also spent more time in the hospital after the stroke than patients with community-onset stroke (17 vs 8 days) and were more likely to be dead or disabled at discharge and less likely to be discharged home from the hospital.

Dr. Kapral said it’s “very important to recognize that patients with in-hospital stroke were really very different” from the community-onset stroke population. They were older and more likely to have serious medical conditions like heart failure and cancer and had more severe strokes and therefore less likely to be eligible for thrombolysis because of contraindications. “Even with optimal care these patients are less likely to do well after stroke,” she said.

In his editorial, Dr. Dulli notes that in-hospital stroke is a “large problem,” representing between 4 and 17 percent of all acute stroke, with “unique challenges.” In the current study, “Nearly half the in-hospital strokes occurred on surgical services, and perhaps for many of them a perioperative contraindication to thrombolytic therapy was the basis for not using code stroke. More of the patients with in-hospital stroke were drowsy or moribund due to their admitting illnesses and medications for these. In such situations both the time of symptom onset and contribution to patients’ overall deficits may have been felt to be too obscure; no code stroke was felt to be warranted,” he points out.

“Whatever the reasons for this delay, these studies reveal a paradox in which a critical therapy is limited or delayed in a group of patients whose need for it may be greater,” Dr. Dulli writes.

Recognition of in-hospital stroke is a “major problem,” he said in the JAMA Neurology podcast. “The most striking outcome” in this study was the delay in symptom recognition and neuroimaging.

“It’s clear that there needs to be more of a protocol-driven approach to in-hospital stroke both in terms of recognition and what to do when stroke is recognized or suspected,” he said.

The Canadian Stroke Network supported this study.