Inverse relationship of baseline body temperature and outcome between ischemic stroke patients treated and not treated with thrombolysis: the Bergen stroke study

BACKGROUND

High body temperature may promote clot lysis whereas low body temperature is neuroprotective in patients with cerebral infarction. We hypothesized that high body temperature is associated with favorable outcome in patients treated with tissue plasminogen activator (tPA) and that low body temperature is associated with favorable outcome in patients not treated with tPA.

METHODS

Patients (n = 111) who were treated with tPA and patients (n = 139) who were not treated with tPA, but presented within 6 h of stroke onset were included. Patients with no temperature measurements within 6 h of stroke onset were excluded. National Institute of Health Stroke Scale (NIHSS) score was obtained on admission. Modified Rankin score (mRS) was obtained after 1 week. Favorable outcome was defined as mRS 0-2 and unfavorable outcome as mRS 3-6.

RESULTS

On logistic regression analysis, high body temperature was independently associated with favorable outcome among patients treated with tPA (OR = 3.7, P = 0.009) and low body temperature was independently associated with favorable prognosis among patients not treated with tPA (OR = 2.0, P = 0.042).

CONCLUSIONS

Our study suggests that the effect of high body temperature on clot lysis is more important than the neuroprotective effect of low body temperature in the early phase after cerebral infarction treated with tPA.

[Thrombolytic therapy in cerebral infarction]

BACKGROUND

Intravenous thrombolysis has gained widespread acceptance during the last 10 years, and is the only specific treatment approved for cerebral infarction. Haukeland University hospital introduced thrombolysis in 1998. The aim of this paper is to summarize our experience with the first 100 patients who had stroke caused by middle cerebral artery (MCA) occlusion and were treated with thrombolysis.

MATERIALS AND METHODS

Patients receiving intravenous thrombolytic treatment between 1998 and 2005 were prospectively included into our database. We registered demographic data, risk factors, time aspects, short and long-term clinical results and complications.

RESULTS

Two hours after treatment, a definite clinical improvement was recorded in 30 % of patients, and after 24 hrs in 49 % of the patients. Symptomatic haemorrhages were seen in 2 % of the cases. Three patients underwent haemicraniectomy because of malignant cerebral oedema and danger of hernia. At three months follow-up, 55 % of the patients had a good outcome (independence), while 13 % were dead. Time from stroke onset to start of thrombolysis was reduced from 166 to 142 min during the study period.

INTERPRETATION

The results for the first 100 acute MCA stroke patients treated with thrombolysis in Haukeland University Hospital compare well with international data, both for clinical outcome and complications. Our results thereby support the notion that intravenous thrombolysis is effective and safe when applied as a routine treatment in a comprehensive stroke unit.

Clinical presentation and diffusion weighted MRI of acute cerebral infarction. The Bergen Stroke Study

Background

No large study has compared the yield of diffusion-weighted imaging (DWI) with clinical examination in order to differentiate lacunar stroke from other stroke subtypes. This differentiation is important for guiding further investigations and treatment.

Methods

Consecutive patients admitted with cerebral infarction were classified according to the Oxfordshire Community Stroke Project scale. Based on DWI and CT stroke was classified as lacunar (LI) and non-lacunar (NLI). Acute ischemic lesion <1.5 cm and located in subcortex or in brainstem were classified as LI. All other infarctions were classified as NLI.

Results

DWI was performed in 419 (69%) patients. Among patients with lacunar syndrome (LACS) 45 (40.5%) had NLI on DWI. All patients with total anterior syndrome (TACS) and 144 (88.3%) with partial anterior syndrome (PACS) had NLI on DWI.

Conclusion

DWI is important among patients presenting with clinical symptoms suggestive of lacunar syndrome to differentiate between LI and NLI. On the other hand, there is good correspondence between TACS or PACS and NLI on DWI.

Admission C-reactive protein after acute ischemic stroke is associated with stroke severity and mortality: the 'Bergen stroke study'

Background

There is growing evidence that inflammation plays an important role in atherogenesis. Previous studies show that C-reactive protein (CRP), an inflammatory marker, is associated with stroke outcomes and future vascular events. It is not clear whether this is due a direct dose-response effect or rather an epiphenomenon. We studied the effect of CRP measured within 24 hours after stroke onset on functional outcome, mortality and future vascular events.

Methods

We prospectively studied 498 patients with ischemic stroke who were admitted within 24 hours after the onset of symptoms. CRP and NIH stroke scale (NIHSS) were measured at the time of admission. Short-term functional outcome was measured by modified Rankin scale (mRS) and Barthel ADL index (BI) 7 days after admission. Patients were followed for up to 2.5 years for long-term mortality and future vascular events data.

Results

The median CRP at admission was 3 mg/L. High CRP was associated with high NIHSS (p = 0.01) and high long-term mortality (p < 0.0001). After adjusting for confounding variables, high CRP remained to be associated with high NIHSS (p = 0.02) and high long-term mortality (p = 0.002). High CRP was associated with poor short-term functional outcomes (mRS > 3; BI < 95) (p = 0.01; p = 0.03). However, the association was not significant after adjusting for confounding variables including stroke severity (p = 0.98; p = 0.88). High CRP was not associated with future vascular events (p = 0.98).

Conclusion

Admission CRP is associated with stroke severity and long-term mortality when measured at least 24 hours after onset. There is a crude association between high CRP and short-term functional outcome which is likely secondary to stroke severity. CRP is an independent predictor of long-term mortality after ischemic stroke.

Disappearing hyperdense middle cerebral artery sign in ischaemic stroke patients treated with intravenous thrombolysis: clinical course and prognostic significance

BACKGROUND AND PURPOSE

Hyperdense middle cerebral artery sign (HMCAS) on CT is a well known indication of thromboembolic arterial occlusion. Its disappearance after thrombolytic therapy is poorly described. Taking the rate of HMCAS disappearance as a surrogate for MCA recanalisation, its prognostic value after intravenous thrombolysis was examined.

METHODS

1905 stroke patients with HMCAS on admission CT scan in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) were studied. On follow-up CT scans 22-36 h after thrombolysis, HMCAS disappeared in 831 cases, persisted in 788 and was uncertain in 122; follow-up CT was not done in 164 cases.

RESULTS

Patients whose HMCAS disappeared were younger (median age 67 years vs 69 years for persistent; p = 0.03), with milder stroke (admission National Institute of Health Stroke Scale (NIHSS) score was 16 vs 17; p<0.005) and were less likely to have early infarct signs on admission CT (26% vs 33%; p<0.005). Patients with disappearing HMCAS were more likely to have early improvement in NIHSS score (median improvement 2 vs 0 at 2 h; 4 vs 1 at 24 h), be independent at 3 months (42% vs 19%), with fewer deaths (15% vs 30%) than those with persistent HMCAS. In multivariate analysis, HMCAS disappearance independently predicted functional independence and survival. Early NIHSS improvement independently predicted HMCAS disappearance.

CONCLUSIONS

HMCAS disappeared after intravenous thrombolysis in about half of cases and these patients had twice as good outcomes compared with those with persistent HMCAS. The prognosis in patients with MCA occlusion that persists after intravenous thrombolysis is poor, which may indicate the need for an alternative treatment approach to this subgroup.

The effect of physiologic derangement in patients with stroke treated with thrombolysis

BACKGROUND

Body temperature, blood glucose, and blood pressure (BP) may interfere with outcome in patients with acute ischemic stroke treated with thrombolysis.

METHODS

We prospectively studied 127 patients who received thrombolysis with tissue plasminogen activator for acute stroke in Bergen, Norway. Body temperature, blood glucose, and BP were measured before thrombolysis. Maximum body temperature and maximum blood glucose within the first 5 days after thrombolysis and maximum BP within the first 24 hours after thrombolysis were measured. The outcome was measured with modified Rankin scale score obtained at 3 months after stroke onset. Variables were tested using multiple logistic regression analysis after adjusting for National Institute of Health Stroke Scale score before thrombolysis and potential confounders.

RESULTS

The average age of the patients was 63 years and the median National Institute of Health Stroke Scale score was 13. On admission, diabetes mellitus was present in 6% of patients and hypertension in 51% of patients. High body temperature and high blood glucose after thrombolysis were associated with poor prognosis (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.29-6.25, P = .01; OR 1.33, 95% CI 1.02-1.74, P = .03). High body temperature and high blood glucose before thrombolysis were not associated with outcome (OR 0.79, 95% CI 0.39-1.58, P = .5; OR 1.04, 95% CI 0.75-1.20, P = .08). High systolic BP both before and after thrombolysis was associated with poor outcome (OR 1.27, 95% CI 1.03-1.52, P = .025; OR 1.22, 95% CI 1.00-1.44, P = .045). High diastolic BP both before and after thrombolysis was not associated with outcome (OR 1.03, 95% CI 0.97-1.36, P =.85; OR 1.16, 95% CI 0.99-1.46, P = .29).

CONCLUSIONS

The current study indicates that in patients with ischemic stroke, high body temperature and high blood glucose after thrombolysis are associated with poor prognosis. Frequent monitoring of these parameters and the appropriate treatment of it, if elevated, are important during the first few days after thrombolysis. High systolic BP both before and after thrombolysis was associated with poor outcome. This finding may support the practice of reducing systolic BP below 185 mm Hg both before and after thrombolysis.

Ultrasound, atherosclerosis and stroke at a young age: a cross-sectional long-term follow-up in western Norway

BACKGROUND AND PURPOSE

Previous studies have shown significantly higher mortality and vascular morbidity amongst patients with ischaemic stroke onset at a young age compared with controls after a mean observation time of more than 11 years.

METHODS

In the present cross-sectional study, we measured the carotid intima-media thickness (IMT) in 140 (75%) of 187 survivors of ischaemic stroke after a mean observation time of 11.9 years. Their mean age when included was 41.1 years. IMT was measured by B-mode ultrasonography.

RESULTS

Total maximum IMT <1.0 mm was found in 34 (24%) patients, [1.0-1.2 mm) in 29 (21%) patients, [1.2-1.5 mm) in 29 (21%) patients and >or=1.5 mm in 48 (34%) patients. Increasing total maximum IMT was related to increasing age, male gender, recurrent ischaemic stroke, coronary atherosclerosis, peripheral atherosclerosis, smoking, hypertension and diabetes mellitus.

DISCUSSION

IMT changes confirm increased vascular morbidity in patients who suffered ischaemic stroke at a young age.

Long-term mortality among young ischemic stroke patients in western Norway

OBJECTIVES

To obtain data on long-term mortality among young ischemic stroke patients compared with controls in this population-based study.

MATERIAL AND METHODS

We used Kaplan-Meier survival analysis to compare 232 patients aged 15-49 years with first-ever cerebral infarction in 1988-1997 and 453 controls followed from inclusion to death or 1 August 2005 for 2515 and 5558 person-years respectively. In a subanalysis of 192 patients, we compared risk factor variables using the Kaplan-Meier method and log-rank testing. We applied a Cox proportional hazards model to adjust for multiple risk factors.

RESULTS

Forty-five patients and nine controls died during follow-up (P < 0.0005). Independent risk factors for mortality were active tumor disease (P < 0.0005), high consumption of alcohol (P < 0.0005), coronary atherosclerosis (P < 0.001), living alone (P < 0.02), seizures (P < 0.04) and smoking (P = 0.08).

CONCLUSIONS

Long-term mortality was significantly increased among young stroke patients, mainly due to such lifestyle factors as high consumption of alcohol and tobacco.

Assessment of atopic eczema: clinical scoring and noninvasive measurements

BACKGROUND

Clinical scoring systems are widely used in clinical trials of atopic eczema (AE), while noninvasive methods are more often used for research purposes. Positive correlations between the two types of methods may be used in support of the validity of both in a clinical context. Few studies are available of the association between clinical scores and instrumental assessment of disease severity obtained with noninvasive instruments.

OBJECTIVES

To compare clinical scores in AE with biometric data in AE.

METHODS

Transepidermal water loss, stratum corneum hydration, erythema, scaling and subepidermal oedema were measured. 'Scoring of Atopic Dermatitis (SCORAD)', 'Eczema Area and Severity Index (EASI)' and 'Atopic Dermatitis Severity Index (ADSI)' were used for clinical scores. Two assessments at 6-month intervals at the antecubital fossa, dorsal forearm and popliteal fossa in 101 patients with AE and 30 controls were carried out.

RESULTS

Significant correlations were found within the clinical scores (P < 0.0001 and r = 0.85-0.91) and between instruments and clinical scores (P < 0.0001 and r = 0.61-0.79).

CONCLUSIONS

The various instruments and clinical scores showed internal agreement and noninvasive methods correlated significantly with the three different clinical scorings systems. This observation suggests that both methods provide data of clinical (scores) and biological (instrumental measures) relevance, and may be useful in future studies of AE. It is speculated that combined measures including scores and selected instruments may be particularly useful.

Occipital lobe infarctions are different

OBJECTIVES

We hypothesized that occipital lobe infarctions differ from infarctions in other locations as to etiology, risk factors and prognosis among young adults.

METHODS

Location, etiology, risk factors and long-term outcome were evaluated among all young adults 15-49 years suffering from cerebral infarction in Hordaland County, Norway between 1988 and 1997.

RESULTS

The following variables were more frequent among patients with occipital lobe infarction compared with patients with infarctions located elsewhere: younger age (P < 0.001), female sex (P = 0.016), prothrombotic state (P = 0.005) and lack of hypertension (P = 0.001). There was no difference as to long-term mortality or recurrence of cerebral infarction.

CONCLUSION

Occipital lobe infarctions differ from infarctions in other locations among young adults. This may have important etiologic and therapeutical implications that need further studies.

Arterial Events after Ischemic Stroke at a Young Age: A Cross-Sectional Long-Term Follow-Up of Patients and Controls in Western Norway

BACKGROUND

There is little information in the literature on the risk of vascular events among patients after ischemic stroke at a young age.

METHODS

We examined 144 (77%) of 187 long-term survivors of ischemic stroke and compared them with 167 controls. Mean age of the 187 survivors at inclusion was 41.0 years and mean age of the participating patients was 40.8 years.

RESULTS

After a mean duration of observation of 11.8 years, we registered arterial events among 54 patients and 14 controls. Ninety patients with index stroke only had no significant risk factors compared with controls without arterial events. Compared with 54 patients with several arterial events, age, incidence of diabetes mellitus, smoking and family history of coronary disease were significantly lower.

CONCLUSIONS

The results from index-stroke-only patients suggest that a subgroup of patients has a benign course, probably without chronic vascular disease.

Endovascular reperfusion therapy in acute ischaemic stroke

OBJECTIVES

Endovascular reperfusion therapy in acute ischaemic stroke comprises a number of pharmacological and mechanical procedures. Mechanical embolectomy offers the promise of efficacious treatment for patients in whom pharmacological thrombolysis is contraindicated or might be ineffective. The purpose of this review is to outline endovascular reperfusion therapy in acute ischaemic stroke with focus on mechanical embolectomy.

MATERIALS & METHODS

Data on endovascular reperfusion therapy were acquired through searches in MEDLINE 1990-2006 by cross referencing relevant key words.

RESULTS

Mechanical embolectomy works well on large-volume proximal occlusions for which there was previously no effective treatment. Early safety trials are promising, efficacy in terms of recanalisation is substantial, and both safety and efficacy is expected to improve with further advances in technology.

CONCLUSIONS

Intravenous thrombolysis with tPA revolutionised acute stroke treatment a decade ago. Endovascular reperfusion therapy now offers the promise of a second revolution, expanding the number of patients eligible and the time window open for specific stroke treatment.

[Treatment of acute ischemic stroke]

BACKGROUND

Treatment of acute ischemic stroke changes rapidly. The purpose of this article is to present current therapeutic options.

MATERIAL AND METHODS

The review is based on relevant literature found through a Medline search and on personal clinical experience.

RESULTS

Acute treatment of ischemic stroke encompasses specific therapy aimed at recanalising the occluded vessel (chemical or mechanical thrombolysis) and treatment aimed at protection from the cellular consequences of ischemia (neuroprotection). Acute treatment also encompasses general stabilisation of a critically ill patient; with focus on blood pressure, cardiovascular function, airways, breathing and metabolic disturbances such as hyperglycemia and hyperthermia. Time is a crucial single factor for treatment effect. A rapid chain of delivery and a well-functioning stroke unit are therefore necessary prerequisites for effective acute stroke treatment.

INTERPRETATION

Effective treatment of acute ischemic stroke is available and should whenever possible be evidence-based. Treatment based on experience and pathophysiological reasoning should be used when scientific evidence lacks.

[Prostate cancer in Denmark 1943-2002]

INTRODUCTION

Previous studies in Denmark have reported an increase in prostate cancer (PC) incidence- and mortality rates. So far, it has not been possible to establish the rising incidence as a consequence of an increase in diagnostic procedures. This study reviews the trends in PC incidence and mortality rates in Denmark during the 60-year-period from 1943 to 2002.

MATERIAL AND METHODS

Register-based study.

RESULTS

The age-standardised (World Standard Population) rate of PC in Denmark increased from 11.4/100,00 in the period 1943-47 to 38.2/100,000 in the period 1998-2002. Mortality rate increased from 13.5/100,000 in 1953 to 19.1/100,000 in the period 1993-98. Within the last 10 years changes in age-distribution and clinical stage, especially among younger patients, indicate a shift towards a more active diagnostic policy.

CONCLUSION

In concordance with other studies we found an increasing PC incidence. In the last 10-year-period studied from 1993 to 2002, our study found the rise in incidence most likely explained by an increase in diagnostic activity, presumably as unsystematic PSA-based "gray-zone screening". This development contrasts with the national recommendation for PSA-based screening for PC. The rising incidence will necessitate allocation of increased resources for evaluation, treatment, and follow-up of patients with PC.

High Incidence of Infarction in the Left Cerebral Hemisphere Among Young Adults

We hypothesized that left cerebral hemisphere infarction is more frequent than right hemisphere infarction among young adults. Furthermore, we aimed to evaluate possible causes for this asymmetry. Cases were found by computer search from hospital registries at each of the 5 acute-care hospitals in a well-defined population in Hordaland County, western Norway. Important parameters used in the analysis were derived from the patient records. A total of 98 patients had left hemisphere infarctions, and 70 patients had right hemisphere infarctions (P = .037). This difference was due mostly to the higher incidence of infarction in the left middle cerebral artery (MCA) territory compared with the right MCA territory among the male subjects (P = .016). Lacunar infarction was equally distributed, whereas nonlacunar infarction was more frequent in the left MCA territory among the men (P = .016). A high frequency of left MCA infarctions may be associated with more frequent atherosclerosis in the left carotid artery, lateralization of cortical functions, or both in young adults.

Instrumental assessment of atopic eczema: Validation of transepidermal water loss, stratum corneum hydration, erythema, scaling, and edema

BACKGROUND

Quantification of skin diseases can be carried out in many ways. Clinical scores are widely used in atopic eczema (AE), and noninvasive instruments are a relevant supplement.

OBJECTIVE

Our purpose was to validate 5 noninvasive instruments in quantification of AE severity.

METHODS

In all, 101 patients with AE and 30 control subjects were assessed twice in a clinical cross-sectional examination. Assessment of transepidermal water loss, stratum corneum hydration, erythema, scaling, and subepidermal edema was assessed on 3 predetermined skin sites.

RESULTS

The methods discriminated among various severity degrees and correlated significantly with objective assessment of disease severity. High correlations were found among instruments assessing acute symptoms of AE. Threshold values for transepidermal water loss and capacitance were found.

LIMITATIONS

No gold standard exists for severity assessment of atopic eczema. Therefore, the methods used cannot be validated in relation to such a standard. Furthermore, atopic eczema is a generalized disease and the methods used assess target lesions. By assessing target lesions, information about the disease is reduced.

CONCLUSION

Noninvasive instruments are valuable in quantification of disease severity in a mixed group of patients with active AE. Assessment with ultrasound has contributed new information about the pathophysiology in AE.

The yield of expanding the therapeutic time window for tPA

OBJECTIVES

Intravenous thrombolysis with recombinant tissue plasminogen activator (tPA) for acute ischemic stroke has been proved to be effective when given within 3 h of onset of stroke symptoms. Partly due to this time limit, less than 10% of stroke patients are treated with tPA. This study assessed the potential for increased tPA utilization with a theoretical time limit of 6 h.

MATERIALS AND METHODS

A total of 117 patients admitted with a diagnosis of acute cerebrovascular disease were prospectively registered over a 3-month period, with emphasis on timing and criteria for tPA treatment.

RESULTS

Eighty-eight of 117 patients (75%) had an acute ischemic stroke. Of these, 23% arrived within 3 h, 8% within 3-6 h, and 69% later than 6 h after symptom onset. Of the seven patients in the 3-6 h group, only one had time delay as the only contraindication to tPA.

CONCLUSIONS

This study suggests that reducing patient delay, rather than increasing the time limit for thrombolytic treatment, may increase the frequency of tPA utilization. Changing time limits for thrombolysis may reduce time delay from stroke onset to arrival in hospital due to more rapid handling of patients by the emergency medical services.

Health-Related Quality of Life Among Young Adults With Ischemic Stroke on Long-Term Follow-Up

Background and Purpose— We sought to compare health-related quality of life (HRQoL) in young adults with ischemic stroke on long-term follow-up with controls and to evaluate HRQoL in clinically relevant patient subgroups.

Methods— HRQoL was determined with the use of the 8 subscales of the Short-Form General Health Survey (SF-36). Subgroups of patients were defined by sex, age, functional status (modified Rankin Scale), marital status, education, depression (Montgomery-Åsberg Depression Rating Scale), and fatigue (Fatigue Severity Scale). SF-36 scores among patients were compared with SF-36 scores among age- and sex-matched controls and SF-36 scores available from the general Norwegian population.

Results— SF-36 scores were obtained after a mean follow-up of 6.0 years among 190 young adults with ischemic stroke during 1988–1997 and among 215 responding controls (55%). The difference in HRQoL between patients, controls, and the general Norwegian population was restricted mainly to the 3 subscales physical functioning, general health, and social functioning ( P <0.001). Subgroup analysis showed significantly reduced scores for all SF-36 items among patients who were depressed, suffered from fatigue, or unemployed. Linear regression analysis showed that fatigue and depression were major independent variables correlated with low HRQoL.

Conclusions— Compared with controls and the general Norwegian population, low level of HRQoL among young adults with ischemic stroke was most pronounced in regard to physical functioning. Early identification and treatment of depression, fatigue, and physical disability may potentially improve HRQoL among stroke patients.