12 versus 24-hour Bed Rest after Acute Ischemic Stroke Reperfusion Therapy

1. 12 versus 24-hour Bed Rest after Acute Ischemic Stroke Reperfusion Therapy Brian Silver, MD, Tariq Hamid, MD; Muhib Khan, MD; Mario DiNapoli, MD; Reza Behrouz, DO; Gustavo Saposnik, MD; Jo-Ann Sarafin, RNP; Susan Martin, OT; MajazMoonis, MD; Nils Henninger, MD, PhD; Richard Goddeau, MD; Adalia Jun-O’Connell, MD; Shawna M Cutting, MD, MS; Ali Saad, MD; ShadiYaghi, MD; Wiley Hall, MD; Susanne Muehlschlegel, MD, MPH; Raphael Carandang, MD; Marcey Osgood, DO; Bradford B. Thompson, MD; Corey R Fehnel, MD; Linda C. Wendell, MD; N. Stevenson Potter, MD; James M Gilchrist, MD; Bruce Barton, PhD

2. Disclosures • Salary: UMassMemorial Medical Center, University of Massachusetts Medical School, Joint Commission (surveyor) • Consultant fees: Women’s Health Initiative, Medicolegal malpractice review • Honoraria: Ebix publishing, MedLink, Medscape

3. Background • The practice of bed rest for ≥24 hours after reperfusion therapy became standard after the NINDS rt-PA trial. • Yet, the optimal timing of mobilization in these patients is unknown. • Current guidelines recommend against high-dose, very early mobilization within 24 hours of stroke onset as a class III recommendation.

4. Hypothesis • We hypothesized that at a protocol of ≥12 hours bed rest was not inferior to ≥24 hours bed rest following stroke reperfusion therapy. • Secondary hypotheses were that rates of pneumonia, venous thromboembolism, and lengths of stay would be reduced in patients in the ≥12 hours bed rest group.

5. Goals • The goal of the study was to compare discharge outcomes among patients who had ≥24 hours bed rest following acute ischemic stroke reperfusion therapy with ≥12 hours bed rest.

6. Design • Single center • Retrospective • Before and after (January 27, 2014) • Consecutive patients • Adjustments for age, sex, admission NIHSS, time to treatment • Analyses separated by 1) intravenous thrombolysis only patients, and 2) thrombectomy patients with or without intravenous thrombolysis

7. Thrombolysis Only patients

8. Thrombolysis Only patients

9. Thrombolysis Only patients ¹Favorable outcome: discharge to home, home with services, or acute rehabilitation. * P-values from likelihood ratio chi-square test for proportions, from standard two-sample two-sided t-test for normally distributed means, and from Wilcoxon rank sum test for non-normally distributed variables. ** Adjusted for age (continuous), sex (m/f), admission NIHSS (continuous), tPA received (yes/no: including bolus for endovascular treated patients), endovascular treatment (yes/no), and time to treatment (tPA or time to groin puncture, whichever is first). For medical complications, endovascular treatment could not be used in adjustment due to convergence failure. † Odds ratio for 12 hours relative to 24 hours (OR < 1.0 indicates 12 hour outcome lower than 24 hour outcome); difference for 12 – 24 hour outcome (difference < 0.0 indicates 12 hour outcome lower than 24 hour outcome) †† Adjusted p-value for van Elteren non-parametric test to compare non-normal continuous outcomes (NIHSS) between assigned bedtime adjusted for covariates: sex, NIHSS at admission. Resulting score statistic not presented.

10. Thrombectomy Patients (with/without tPA)

11. Thrombectomy Patients (with/without tPA)

12. Thrombectomy Patients (with/without tPA) ¹Favorable outcome: discharge to home, home with services, or acute rehabilitation. * P-values from likelihood ratio chi-square test for proportions, from standard two-sample two-sided t-test for normally distributed means, and from Wilcoxon rank sum test for non-normally distributed variables. ** Adjusted for age (continuous), sex (m/f), admission NIHSS (continuous), tPA received (yes/no: including bolus for endovascular treated patients), endovascular treatment (yes/no), and time to treatment (tPA or time to groin puncture, whichever is first). For medical complications, endovascular treatment could not be used in adjustment due to convergence failure. † Odds ratio for 12 hours relative to 24 hours (OR < 1.0 indicates 12 hour outcome lower than 24 hour outcome); difference for 12 – 24 hour outcome (difference < 0.0 indicates 12 hour outcome lower than 24 hour outcome) †† Adjusted p-value for van Elteren non-parametric test to compare non-normal continuous outcomes (NIHSS) between assigned bedtime adjusted for covariates: sex, NIHSS at admission. Resulting score statistic not presented.

13. Conclusions • Compared with ≥24 hour bed rest, ≥12 hour bed rest after acute ischemic stroke reperfusion therapy appeared to be safe and may be associated with reduced neurological deficit at discharge, shorter length-of-stay, and reduced rates of readmission within 30 days. • A randomized trial is needed to verify these findings.