Acute Ischemic Stroke in the Incarcerated: Comparison of Treatment Rates and Clinical Outcomes With the United States General Population

Article information

J Stroke. 2025;27(3):402-404

Publication date (electronic) : 2025 July 15

doi : https://doi.org/10.5853/jos.2025.00619

Alis J. Dicpinigaitis¹, Mill Etienne², Thanh N. Nguyen³, Ameer E. Hassan⁴, Priyank Khandelwal⁵, Pankajavalli Ramakrishnan², Gabor Toth⁶, Mohammad El-Ghanem⁷, Krishna Amuluru⁸, Viktor Szeder⁹, Jonathan Crow¹⁰, Karol Budohoski¹¹, Zurab Nadareishvilli¹², Kaustubh Limaye¹³, Fazeel Siddiqui¹⁴, Hamza Shaikh¹⁵, Nishita Singh¹⁶, Hesham E. Masoud¹⁷, Tariq Kass-Hout¹⁸, Sushanth Aroor¹⁹, Shashvat Desai²⁰, Santiago Ortega-Gutierrez²¹, Kaiz Asif²², Dileep Yavagal²³, Fawaz Al-Mufti^,2, on Behalf of the Society of Vascular and Interventional Neurology (SVIN)–Mission Thrombectomy Initiative

¹Department of Neurology, New York Presbyterian Hospital – Weill Cornell Medical Center, New York, NY, USA

²Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA

³Department of Neurology, Boston University, Boston, MA, USA

⁴Department of Neuroscience, Valley Baptist Medical Center, Harlingen, TX, USA

⁵Department of Neurosurgery, Rutgers University Medical Center, Newark, NJ, USA

⁶Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA

⁷University of Houston/HCA Houston-NW Medical Center, Houston, TX, USA

⁸Goodman Campbell Brain and Spine, Indianapolis, IN, USA

⁹Department of Neurology, University of California – Los Angeles, Los Angeles, CA, USA

¹⁰Department of Neurology, University of Virginia, Charlottesville, VA, USA

¹¹Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA

¹²Department of Neurology, George Washington University, Washington, D.C., USA

¹³Department of Neurology, Neurological Surgery and Radiology, Indiana University, Indianapolis, IN, USA

¹⁴Department of Neurology, University of Michigan, Wyoming, MI, USA

¹⁵Department of Neurosurgery, Cooper University Medical Center, Camden, NJ, USA

¹⁶Department of Neurology, University of Manitoba, Manitoba, CA, USA

¹⁷Department of Neurology, Upstate Medical University, Syracuse, NY, USA

¹⁸Department of Neurology, University of Chicago Medicine, Chicago, IL, USA

¹⁹Department of Neurology, University of Texas at Houston, Houston, TX, USA

²⁰Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA

²¹Department of Neurology, Neurosurgery, and Radiology, University of Iowa, Iowa City, IA, USA

²²Department of Neurology, Ascension Healthcare, Joliet, IL, USA

²³Department of Neurology, University of Miami, Miami, FL, USA

Correspondence: Fawaz Al-Mufti Department of Neurosurgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY 10595, USA Tel: +1-914-493-5098 E-mail: Fawaz.Al-Mufti@wmchealth.org

Received 2025 February 6; Revised 2025 February 18; Accepted 2025 February 19.

Dear Sir:

Incarcerated individuals in state and federal prisons demonstrate disproportionately high rates of cardiovascular disease, especially hypertension and tobacco use [1]. As a result, in comparison with the United States general population, inmates are faced with a more than three-fold risk of acute ischemic stroke (AIS) [2]. Unfortunately, some evidence suggests that incarcerated individuals receive suboptimal medical care due to structural barriers in healthcare delivery as well as discrimination based on incarcerated status [3], which underscores a public health and human rights concern. To the best of our knowledge, no studies to date have evaluated treatment rates and clinical outcomes of AIS in this specialized population, in whom healthcare outcomes in general are woefully understudied. Herein, we aim to evaluate treatment rates of reperfusion therapies as well as clinical outcomes of incarcerated AIS patients compared to the general population.

Adult hospitalizations for AIS were identified in the 2015–2020 National Inpatient Sample (NIS), a large United States claims-based registry approximating 7,000,000 hospitalizations annually. Clinical variables, including incarcerated status, were identified using the International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes (Z65.1, Y92.14). Rates of endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) in addition to clinical outcomes (routine discharge back to institution/place of residence prior to stroke, acute rehabilitation, length of stay [LOS], and in-hospital mortality) were compared between incarcerated and non-incarcerated individuals by chi-square test. Multivariable logistic regression (MVLRG) analysis controlling for age, race/ethnicity, baseline National Institutes of Health Stroke Scale (NIHSS) score, stroke location (anterior vs. posterior circulation), cardiovascular risk factors (hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, tobacco smoking, and obesity), and treatment modality (EVT, IVT, or best medical therapy) was performed to determine the adjusted association of incarcerated status with routine discharge and mortality. All analyses were performed using IBM SPSS Version 26 software (IBM Corp., Armonk, NY, USA) and incorporated hospitalization weighting to produce accurate national estimates. All data are publicly available through the Healthcare Cost and Utilization Project (HCUP). All diagnostic and procedure codes used for this analysis are available from the authors upon request. Because the data of this analysis reflect publicly available deidentified hospitalization records, it did not meet the requirements for IRB approval.

Among 1,037,020 AIS hospitalizations, 460 (44.4/100,000) documented incarcerated status. Although incarcerated patients were younger than those of the general population (mean age: 56 vs. 69 years), the baseline NIHSS score was comparable (mean score: 6.4 vs. 6.7). Rates of EVT (6.5% vs. 6.7%, P=0.907) and IVT (19.6% vs. 18.1%, P=0.401) did not differ between incarcerated and non-incarcerated individuals, respectively. Incarcerated individuals experienced higher rates of both routine discharge disposition (75.0% vs. 36.6%, P<0.001) as well as acute rehabilitation (5.4% vs. 2.3%, P<0.001) in comparison with non-incarcerated individuals, but mortality rates did not differ (2.2% vs. 3.5%, P=0.115). Mean LOS was significantly greater in the incarcerated population (7.7 vs. 4.8 days, P<0.001). Following MVLRG analysis, incarcerated status was independently associated with routine discharge disposition (adjusted odds ratio [aOR] 4.63, 95% confidence interval [CI] 3.62, 5.92; P<0.001), but not with mortality (aOR 1.04, 95% CI 0.55, 1.97; P=0.906). Sensitivity testing in three separate subgroup analyses of patients receiving acute reperfusion therapies (IVT and/or EVT), in strokes of the posterior circulation, and in high severity strokes (NIHSS >15) confirmed the findings of the primary analysis with respect to discharge disposition and mortality.

This analysis demonstrates that incarcerated individuals with AIS are offered EVT and IVT at comparable rates to the general population and experience favorable clinical outcomes after accounting for age, stroke severity, and cardiovascular risk factors. To the best of our knowledge, analyses of stroke and stroke outcomes in this population are absent from the literature despite the reality that incarcerated people develop stroke at markedly higher rates compared to the general population [2]. Although our findings are encouraging, other literature has unfortunately shown that people in state and federal prisons with active chronic medical issues requiring prescription medication (including hypertension, stroke, diabetes mellitus, cardiac disease, kidney disease, arthritis, asthma, hepatitis, cirrhosis, and HIV/AIDS) fail to receive treatment at alarmingly high rates [4], while other evidence suggests that they receive delays in emergent medical care for acute conditions such as myocardial infarction requiring intervention [5].

It should be noted that the results of our analysis may represent a biased sample of incarcerated patients from particularly conscientious institutions and may not necessarily reflect the broader landscape of stroke care for this vulnerable population in the United States. An alternative explanation for the rather large disparity in rate of routine discharge disposition is that incarcerated individuals had, on balance, longer durations of hospitalization, which may be driven by an inability to find rehabilitation placement. In turn, these patients stay longer and recover enough in the inpatient setting such that rehabilitation may no longer be needed, and they subsequently return to the institution from which they came. Our data, however, show that acute rehabilitation placement rates were, in fact, higher among incarcerated patients, perhaps contradicting this hypothesis. Although the data within the NIS do not capture symptom onset to treatment time, another potential explanation for higher rates of favorable outcome may be that symptoms may be detected earlier due to more rigorous supervision in an institutional setting compared to the general population. The ICD-10-CM diagnostic codes used to identify incarcerated individuals, moreover, were not previously validated and thus may introduce inaccuracies and inconsistencies, nor do they identify specific institutional details (such as state or federal facility or proximity to centers offering acute reperfusion therapies). Finally, a comment should be made regarding limited generalizability of these data beyond the United States, as third world countries may have less supervision and worse conditions, leading to poorer stroke outcomes. Nonetheless, we feel our analysis provides valuable clinical insight in the absence of other data and hope it will encourage further inquiry into treatment and outcomes of AIS in the incarcerated population.