Background and Purpose:While stroke management has evolved rapidly, comprehensive nationwide evidence covering all stroke subtypes remains limited. We evaluated 10-year secular trends in acute stroke care and outcomes in South Korea using a mandatory national quality audit dataset. Methods:Data from the Acute Stroke Quality Assessment Program, covering nearly all general and tertiary hospitals in Korea, were linked with national insurance claims and mortality records. We analyzed 136,191 episodes of ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) from 2013 to 2023. Results:Over the decade, mean patient age increased (67.1 to 69.6 years), with the ≥85-year population doubling (7.2% to 13.4%). An unexplained discrepancy between ambulance use and arrival time emerged: ambulance use rose (55.4% to 61.8%), but median onset-to-arrival time remained stagnant (4.0 hours), with only 36.6% of IS patients arriving within 3 hours. While intravenous thrombolysis utilization remained stable at approximately 6.0% after 2014, endovascular thrombectomy rates more than doubled (5.3% to 11.6%), reaching 41.1% in severe cases. Statin (92.1%), non-vitamin K antagonist oral anticoagulant (78.4%), and dual antiplatelet therapy (67.2%) use increased markedly. In SAH, treatment shifted from clipping (36.7% to 12.2%) to coiling (36.0% to 63.4%). Notably, adjusted mortality exhibited a non-linear U-shaped trend, reaching a nadir in 2018 followed by an uptick after 2020. Conclusions:Despite substantial improvements in inpatient stroke care, the discrepancy between ambulance use and arrival time highlights structural challenges. Furthermore, the U-shaped mortality reversal underscores the vulnerability of healthcare resilience in a super-aging society, particularly under the strain of the COVID-19 pandemic.
Background and Purpose:The optimal prehospital transport strategy for patients eligible for mechanical thrombectomy remains debated. We evaluated how direct versus secondary transfer to a comprehensive stroke center (CSC) influences outcomes in a large metropolitan stroke network. Methods:This prospective registry-based cohort study included all patients undergoing thrombectomy between 2015 and 2022 in a city of 1.7 million inhabitants. The network comprised 11 primary stroke centers (PSCs) referring to a single CSC, all reachable within 60 minutes. Among 2,017 patients, 242 (12.0%) were transported directly to the CSC, whereas 1,775 (88.0%) were secondarily transferred after initial assessment at a PSC. Functional outcome was assessed using the modified Rankin Scale (mRS) at 90 days. Multivariable logistic and Cox regression models were used to identify independent predictors of good functional outcome and survival. Results:The median onset-to-CSC admission time was shorter after direct versus secondary transfer (101 [7-1,071] vs. 240 [40-1,411] min, P<0.001). A good functional outcome (mRS 0-2) was more frequent after direct transport (50.3% vs. 40.5%, P=0.015). After adjustment for age, National Institutes of Health Stroke Scale score, thrombolysis, posterior circulation stroke, and comorbidities, direct transport independently predicted good functional outcome (odds ratio: 1.74; 95% confidence interval [CI] 1.25-2.42; P=0.001). Among patients receiving combined thrombolysis and thrombectomy (n=1,110), direct transport was associated with improved long-term survival (log-rank P=0.026; adjusted hazard ratio: 0.67; 95% CI 0.47-0.95; P=0.026). Conclusions:Even within a metropolitan network with 1-hour access, direct transport to a CSC shortens treatment delays, improves functional recovery, and enhances survival among patients undergoing combined reperfusion therapy.
Acute brain injury (ABI) affects up to one-third of patients using mechanical circulatory support (MCS). In venoarterial extracorporeal membrane oxygenation (VA ECMO), ABI incidence (11%–40%) has not improved in two decades. Conversely, improvements in left ventricular assist devices (LVADs) have reduced the incidence of stroke, although it remains a major complication (10%–30%). The failure of MCS to ensure adequate cerebral protection may impair cerebrovascular autoregulation (CVAR) and disrupt microcirculatory function affected by reduced pulsatility, endothelial injury, acute perturbations in partial pressure of arterial carbon dioxide (PaCO2), and cerebral venous congestion. Here, we review evidence demonstrating that these factors alter microcirculatory dynamics and CVAR, thereby contributing to ABI through shared mechanistic pathways. Current methods for assessing CVAR are reviewed, including invasive indices such as the pressure reactivity index (PRx) from intracranial pressure monitoring and noninvasive metrics such as the cerebral oximetry index (COx) from near-infrared spectroscopy or flow-velocity correlations from transcranial Doppler. Each method is limited by feasibility, signal artifacts, and inter-modality variability. Our review identifies three priority areas for cerebral protection in MCS: preservation of pulse pressure, cautious titration of PaCO2, and integration of CVAR-informed blood pressure management. Preliminary evidence suggests that very low pulse pressure, rapid carbon dioxide correction, and persistent microcirculatory impairment are each associated with ABI risk. Future investigations should focus on validating bedside tools to assess CVAR and microcirculatory integrity, and on determining whether physiological targets derived from these measures can improve neurological outcomes in patients using MCS.
