Better outcome after stroke with higher serum cholesterol levels

Statin use prior to ischemic stroke onset is associated with decreased in-hospital mortality

Statins can reduce the risk of stroke in at-risk populations and improve survival after acute ischemic stroke (AIS) among patients with previous statin use. This study aimed to investigate the impact of statin use before AIS onset on in-hospital mortality and identify the factors related to in-hospital mortality among patients with and without previous statin use. A retrospective cohort study of all patients with AIS attending hospital from June 1, 2008 to December 31, 2008. Data were collected from medical records including demographic information, diagnostic information, risk factors, previous statin use, and vital discharge status. Chi-square, Fisher's exact tests, student's t-test, and Mann-Whitney U test, whatever appropriate, were used to test the significance between the variables, and multiple logistic regression was used to identify factors associated with in-hospital mortality. Altogether, 386 patients with AIS were studied, of which 113 (29.3%) had a documented previous statin use. A total of 62 (16.1%) patients with AIS died in hospital. In-hospital mortality was significantly lower among previous statin users (P = 0.013). The presence of atrial fibrillation (AF) increased in-hospital mortality among patients with or without previous statin use. The independent predictors for in-hospital mortality among AIS patients without previous statin use were the presence of diabetes mellitus (P = 0.047), AF (P = 0.045), and renal impairment (P < 0.001). The prophylactic administration of statins significantly reduces post-AIS in-hospital mortality. Furthermore, the identification of predictors of in-hospital mortality might reduce death rates and enhance the application of specific therapeutic and management strategies to patients at a high risk of dying.

Factors associated with functional outcomes of patients with cerebral embolism due to nonvalvular atrial fibrillation

OBJECTIVE

This study aimed to identify factors associated with the functional outcomes of patients with cerebral embolism due to nonvalvular atrial fibrillation.

METHODS

We retrospectively investigated the short-term functional outcomes of 134 patients diagnosed with cardiogenic cerebral embolism due to nonvalvular atrial fibrillation during the period of May 2006 to August 2008. Functional state was evaluated using the modified Rankin Scale (mRS) on admission and at discharge.

RESULTS

A good functional outcome (mRS ≤2) at discharge was significantly associated with low mRS on admission (OR: 0.07; CI: 0.03-0.18; p<0.001), and a low C-reactive protein (CRP) level (OR: 0.19; CI: 0.04-0.89; p<0.05). Functional improvement during admission was positively associated with the presence of dyslipidemia (OR: 2.74; CI: 1.11-6.76; p<0.05), whereas high diastolic blood pressure (OR: 0.95; CI: 0.90-0.99; p<0.05) and a high blood sugar level (OR: 0.98; CI: 0.97-0.99; p<0.05) on admission were inversely associated with functional improvement. Furthermore, no relationship existed between mRS on admission and functional improvement during hospitalization.

CONCLUSION

The results suggest that a good functional state at discharge was associated with a good functional state on admission as well as a low serum CRP level. On the other hand, functional improvement was associated with the presence of dyslipidemia, low diastolic blood pressure, and low blood sugar level on admission.

Long-term prognosis of ischemic stroke in young adults

There is limited information about long-term prognosis of ischemic stroke in young adults. Giving the potentially negative impact in physical, social, and emotional aspects of an ischemic stroke in young people, providing early accurate long-term prognostic information is very important in this clinical setting. Moreover, detection of factors associated with bad outcomes (death, recurrence, moderate-to-severe disability) help physicians in optimizing secondary prevention strategies. The present paper reviews the most relevant published information concerning long-term prognosis and predictors of unfavorable outcomes of ischemic stroke affecting young adults. As a summary, we can conclude that, in the long term, stroke in the young adult increases slightly the risk of mortality, implies higher risk of future cardiovascular events, and determines functional limitations in a significant percentage of patients. Nevertheless, in every individual case the prognosis has to be considered depending on several factors (stroke subtype, initial severity, cardiovascular risk factors) that determine the long-term outcomes.

Prescription of lipophilic statins to Alzheimer's disease patients: some controversies to consider

Alzheimer's disease (AD) is the most common disorder causing cognitive decline in old age. It is a progressive and irreversible neuropathology with a diagnosis often missed or delayed. Cholesterol represents an important determinant of the physical state of biological membranes and in AD brains, specific changes in its membrane-ordering and Raft-organizing effects take place. A recent publication shows downregulation of Seladin-1 (selective Alzheimer's disease indicator, also called DHCR24), which catalyzes the last step of cholesterol biosynthesis in affected neurons in AD. Postmortem analysis of AD brains revealed a loss in membrane cholesterol content and this finding makes the therapeutical use of statins (especially the lipophilic ones) quite a lot controversial. Some clinical studies suggest that risk of Alzheimer's disease is substantially reduced in users of statins; however, because these studies are not randomized trials, they provide insufficient evidence to recommend statin family therapy.

Risk Score for In-Hospital Ischemic Stroke Mortality Derived and Validated Within the Get With The Guidelines–Stroke Program

Background—

There are few validated models for prediction of in-hospital mortality after ischemic stroke. We used Get With the Guidelines–Stroke Program data to derive and validate prediction models for a patient's risk of in-hospital ischemic stroke mortality.

Methods and Results—

Between October 2001 and December 2007, there were 1036 hospitals that contributed 274 988 ischemic stroke patients to this study. The sample was randomly divided into a derivation (60%) and validation (40%) sample. Logistic regression was used to determine the independent predictors of mortality and to assign point scores for a prediction model. We also separately derived and validated a model in the 109 187 patients (39.7%) with a National Institutes of Health Stroke Scale (NIHSS) score recorded. Model discrimination was quantified by calculating the C statistic from the validation sample. In-hospital mortality was 5.5% overall and 5.2% in the subset in which NIHSS score was recorded. Characteristics associated with in-hospital mortality were age, arrival mode (eg, via ambulance versus other mode), history of atrial fibrillation, previous stroke, previous myocardial infarction, carotid stenosis, diabetes mellitus, peripheral vascular disease, hypertension, history of dyslipidemia, current smoking, and weekend or night admission. The C statistic was 0.72 in the overall validation sample and 0.85 in the model that included NIHSS score. A model with NIHSS score alone provided nearly as good discrimination (C statistic 0.83). Plots of observed versus predicted mortality showed excellent model calibration in the validation sample.

Conclusions—

The Get With the Guidelines–Stroke risk model provides clinicians with a well-validated, practical bedside tool for mortality risk stratification. The NIHSS score provides substantial incremental information on a patient's short-term mortality risk and is the strongest predictor of mortality.

Statins and clinical outcome of acute ischemic stroke: a systematic review

BACKGROUND

Statin therapy is considered an effective measure for the prevention of ischemic stroke. Several recent studies have indicated that treatment with statins, prior to the onset of acute ischemic stroke, may also substantially reduce the severity of stroke and the degree of patient disability. The purpose of the present review is to systematically evaluate the effectiveness of statin pretreatment on functional outcome of acute ischemic stroke and to assess potential adverse events associated with statin use.

METHODS

Relevant articles on the role of statins in acute ischemic stroke were identified via MEDLINE/PubMed, EMBASE, CENTRAL, and by manual searches of the references of identified papers. Clinical studies (most were prospective cohort studies) assessing statin therapy for acute ischemic stroke were selected for the review. Only two randomized controlled clinical trials met the criteria to be included in the analysis. Clinical outcome was assessed based on the degree of disability determined with the modified Rankin Scale (mRS) and Barthel index (BI). The National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity. Recurrence of stroke in patients who had suffered from a previous stroke was analyzed with and without statin therapy. Incidence and severity of adverse reactions was reviewed. Because there were too many differences in study outcome measures, a quantitative analysis of data was deemed inappropriate. A qualitative summary of the data was consequently completed.

RESULTS

Thirteen reports were systematically reviewed to evaluate the efficacy and safety of statins in the pretreatment of acute ischemic stroke. Pretreatment with statins was found to reduce the recurrence of stroke and to result in more favorable outcomes for patients. The beneficial effects of prior statin therapy in acute ischemic stroke were shown to be especially profound in whites, diabetics, elderly patients with hypertension and other vascular diseases, and in patients with ideal low density lipoprotein (LDL) levels. There were few incidences of adverse reactions with statin pretreatment, most of which were not statistically significant.

CONCLUSIONS

Pretreatment with statins was associated with a favorable outcome in acute ischemic stroke, with few incidences of adverse reactions.

Pretreatment with statins improves early outcome in patients with first-ever ischaemic stroke: a pleiotropic effect of statins or a beneficial effect of hypercholesterolemia?

Background

Data from different studies suggest a favourable association between pretreatment with statins or hypercholesterolemia and outcome after ischaemic stroke. We examined whether there were differences in in-hospital mortality according to the presence or absence of statin therapy in a large population of first-ever ischaemic stroke patients and assessed the influence of statins upon early death and spontaneous neurological recovery.

Methods

In 2,082 consecutive patients with first-ever ischaemic stroke collected from a prospective hospital-based stroke registry during a period of 19 years (1986-2004), statin use or hypercholesterolemia before stroke was documented in 381 patients. On the other hand, favourable outcome defined as grades 0-2 in the modified Rankin scale was recorded in 382 patients.

Results

Early outcome was better in the presence of statin therapy or hypercholesterolemia (cholesterol levels were not measured) with significant differences between the groups with and without pretreatment with statins in in-hospital mortality (6% vs 13.3%, P = 0.001) and symptom-free (22% vs 17.5%, P = 0.025) and severe functional limitation (6.6% vs 11.5%, P = 0.002) at hospital discharge, as well as lower rates of infectious respiratory complications during hospitalization. In the logistic regression model, statin therapy was the only variable inversely associated with in-hospital death (odds ratio 0.57) and directly associated with favourable outcome (odds ratio 1.32).

Conclusions

Use of statins or hypercholesterolemia before first-ever ischaemic stroke was associated with better early outcome with a reduced mortality during hospitalization and neurological disability at hospital discharge. However, statin therapy may increase the risk of intracerebral haemorrhage, particularly in the setting of thrombolysis.

Hyperlipidemia and reduced white matter hyperintensity volume in patients with ischemic stroke

BACKGROUND AND PURPOSE

White matter hyperintensity (WMH), or leukoaraiosis, is a radiologic finding generally assumed to reflect diseased small cerebral vasculature. WMH has significant functional impact through its relation to cognitive decline and risk of ischemic and hemorrhagic stroke. Accumulating evidence suggests that some manifestations of small-vessel disease such as intracerebral hemorrhage are associated with low levels of cholesterol. We sought to determine the relation between hyperlipidemia and WMH severity in patients with acute ischemic stroke (AIS).

METHODS

We analyzed 2 independent, hospital-based AIS cohorts. Demographic and clinical data were collected prospectively. WMH was measured using semiautomated volumetric image analysis and a semiquantitative visual grading scale. Univariate and multivariable regression analyses were used to assess the relation between WMH severity and study variables.

RESULTS

A total of 631 and 504 subjects in the first and second cohorts, respectively, were included. In univariate analyses, advancing age and hypertension were associated with severity of WMH (P<0.001) in both cohorts. In the multivariable analysis, after controlling for age, sex, and significant risk factors in the univariate and age-adjusted analyses, patients with a history of hyperlipidemia had less severe WMH in both cohorts (P<0.01).

CONCLUSIONS

Results from 2 independent cohorts demonstrate that AIS patients with a history of hyperlipidemia have less severe WMH at the time of stroke. These data support the hypothesis that hyperlipidemia may play a relatively protective role in cerebral small-vessel disease.

Impact of hyperlipidemia and statins on ischemic stroke outcomes after intra-arterial fibrinolysis and percutaneous mechanical embolectomy

BACKGROUND

Endovascular recanalization therapies are an increasingly employed treatment strategy in acute cerebral ischemia. The determinants of the final clinical outcome after endovascular treatment have been understudied. We investigated the effects of hyperlipidemia and statins on acute ischemic stroke outcomes after endovascular procedures.

METHODS

An inquiry of a prospectively maintained stroke registry was conducted. Endovascular procedures were performed using recombinant tissue plasminogen activator, prourokinase or the Merci device within 12 hours after symptom onset. The analyzed outcomes were revascularization, hemorrhage and excellent functional outcome (Rankin score of 0-1 at 3 months). The analyses included chi(2) and Wilcoxon rank sum, logistic regression (for multivariate analyses with binary outcomes) and linear regression (for continuous outcomes). Significance was set at p < 0.05.

RESULTS

We included 142 patients, 80% treated with intra-arterial fibrinolysis, 22% with percutaneous mechanical embolectomy and 27% treated with intravenous fibrinolysis prior to endovascular intervention. Age (OR = 0.956, 95% CI = 0.927-0.986, p = 0.0041), National Institutes of Health Stroke Scale (NIHSS) score on admission (OR = 0.881, 95% CI = 0.812-0.957, p = 0.0025) and history of hyperlipidemia (OR = 0.284, 95% CI = 0.08-0.99, p = 0.0478) were negatively associated with excellent functional outcome at 3 months. Every 50 mg/dl increment in the total cholesterol level resulted in 64% decrease in the odds of excellent functional outcome (OR = 0.36, 95% CI = 0.447-0.882, p = 0.0253). History of hyperlipidemia decreased the likelihood of neurological improvement (p = 0.0462) and was associated with a higher NIHSS score at 7 days or discharge. Statin use was related to an average 6.5-unit NIHSS decrease at discharge (p = 0.0168). Statins were not associated with increased frequency of recanalization or symptomatic intracerebral hemorrhage.

CONCLUSIONS

History of hyperlipidemia may have a negative impact on the outcomes of acute ischemic stroke treated with intra-arterial fibrinolysis or percutaneous mechanical embolectomy. Statin use before and after these procedures may be related to better neurological outcomes. Larger prospective studies are needed to endorse these findings.

Interventions in the management of serum lipids for preventing stroke recurrence

BACKGROUND

Studies have shown that interventions which reduce total and low-density lipoprotein cholesterol levels also reduce coronary heart disease (CHD) and stroke events in those with a history of CHD. However, it is uncertain whether treatment to alter cholesterol levels can prevent recurrence of either stroke or subsequent cardiovascular events and whether differences in outcomes exist between classes of lipid-lowering therapy. This is an update of a Cochrane review first published in 2002.

OBJECTIVES

To investigate the effect of altering serum lipids pharmacologically for preventing subsequent cardiovascular disease and stroke recurrence in patients with a history of stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched December 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2008), MEDLINE (1966 to December 2008) and EMBASE (1980 to December 2008). We contacted pharmaceutical companies known to produce a lipid-lowering agent for information on relevant publications or unpublished work.

SELECTION CRITERIA

Unconfounded randomised trials of participants aged 18 years and over with a history of stroke or transient ischaemic attack (TIA).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality and extracted data.

MAIN RESULTS

We included eight studies involving approximately 10,000 participants. The active interventions were pravastatin, atorvastatin, simvastatin, clofibrate, and conjugated oestrogen. Fixed-effect analysis showed no overall effect on stroke recurrence but statin therapy alone had a marginal benefit in reducing subsequent cerebrovascular events in those with a previous history of stroke or TIA (odds ratio (OR) 0.88, 95% confidence interval (CI) 0.77 to 1.00). There was no evidence that such intervention reduced all-cause mortality or sudden death (OR 1.00, 95% CI 0.83 to 1.20). Three statin trials showed a reduction in subsequent serious vascular events (OR 0.74, 95% CI 0.67 to 0.82).

AUTHORS' CONCLUSIONS

There is evidence that statin therapy in patients with a history of ischaemic stroke or TIA significantly reduces subsequent major coronary events but only marginally reduces the risk of stroke recurrence. There is no clear evidence of beneficial effect from statins in those with previous haemorrhagic stroke and it is unclear whether statins should be started immediately post stroke or later. In view of this and the evidence of the benefit of statin therapy in those with a history of CHD, patients with ischaemic stroke or TIA, with or without a history of established CHD, should receive statins.

Administration of free radical scavenger edaravone associated with higher frequency of hemorrhagic transformation in patients with cardiogenic embolism

Free radicals are known to activate coagulation and inhibit fibrinolysis. Edaravone, a free radical scavenger, protects vascular endothelial cells and neurons during acute brain ischemia in in vitro models. Hemorrhagic transformation and treatment outcomes were retrospectively examined in 76 patients with acute cardiogenic embolism treated with edaravone in addition to routine treatment within 24 hours of the onset of symptoms. Hemorrhagic transformation was categorized according to European Cooperative Acute Stroke Study-II. Patient characteristics were also evaluated, including evidence of hypertension, diabetes mellitus, hyperlipidemia, coronary heart disease, history of smoking, National Institutes of Health Stroke Scale on arrival, and modified Rankin scale at 3 months post-onset. Edaravone administration was one of the factors that contributed to increased frequency of hemorrhagic transformation, but had showed no significant relationship with the outcome. The present study showed that edaravone administration increased the frequency of hemorrhagic transformation with heparin in patients with cardiogenic embolism. Free radical scavenging may have promoted the coagulating conditions. Edaravone administration may allow reduction of the dose of heparin and tissue plasminogen activator in patients with acute ischemic stroke.

Serum cholesterol levels do not influence outcome or recovery in acute ischemic stroke

OBJECTIVE

To examine the influence of admission serum cholesterol levels (SCL) on severity of initial neurological deficit, neurological outcome at month 3 and neurological recovery in patients with acute first-ever ischemic stroke.

METHODS

Prospectively collected data from 889 consecutive patients with first-ever acute ischemic stroke were retrospectively analysed. Patients who suffered a recurrent ischemic stroke (n=22) or died (n=30) during the follow-up period were excluded from this study. Age, gender, arterial hypertension, diabetes mellitus, smoking, stroke etiology, SCL and severity of neurological deficit, using the National Institute of Health Stroke Scale (NIHSS), at presentation (NIHSS0) and after 3 months (NIHSS1), were assessed. Neurological recovery was defined as difference in NIHSS score (Delta(NIHSS)), according to Delta(NIHSS)=NIHSS0 - NIHSS1.

RESULTS

Data from 837 patients (66% men, age: 62 +/- 14 years) were analysed. NIHSS1 was 2.3 +/- 1.8 and Delta(NIHSS) was 3.4 +/- 3. Clinically insignificant correlations between SCL and NIHSS0 (r=-0.13, p=0.0002), NIHSS1 (r=-0.09, p=0.001) and Delta(NIHSS) (r=-0.1, p=0.03) were evident. Multivariate binary logistic regression analysis revealed smoking (p=0.008), stroke etiology (p=0.023) and NIHSS0 (p<0.001) but not age, gender, arterial hypertension, diabetes mellitus or SCL as predictors for Delta(NIHSS).

CONCLUSION

Our data suggest that SCL in patients with acute ischemic stroke are not associated with neurological deficit on admission, outcome or neurological recovery.

Serum lipid levels and 3-month prognosis in Chinese patients with acute stroke

INTRODUCTION

The possible correlation between serum lipid levels and outcome after stroke is still controversial. Therefore we examined whether serum lipid levels at admission had any prognostic value in the 3-month outcome after stroke.

METHODS

We performed a prospective, observational study of 649 patients with acute ischaemic stroke and intracerebral haemorrhagic stroke (ICH). Information on age, sex, history of arterial hypertension, diabetes mellitus, drinking, current smoking status, stroke type, Glasgow Coma Scale and Scandinavian Stroke Scale score, time from stroke onset, and presence of atrial fibrillation was obtained. Serum lipid levels were measured in blood samples taken from fasting patients 12 to 48 hours following ictus. Death and poor neurological outcome (Modified Rankin Scale score of > or =3 points) were defined as outcome events. A logistic regression model was performed to estimate the effect of the above variables on outcome after stroke.

RESULTS

We found that the median levels of serum total cholesterol (TC), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C) in good outcome patients with acute stroke were significantly higher (P<0.005) than those of poor outcome patients. The low levels of serum TC, TG and HDL-C (P<0.05) were independently related to increased 3-month poor outcome after acute ischaemic stroke and ICH. However, there was no significant relationship between LDL-C levels and 3-month outcome.

CONCLUSION

The data from this study show that low levels of serum TC, TG and HDL-C are strong independent predictors of 3-month poor outcome in patients with acute ischaemic stroke and ICH.

Classical conditioning of the rabbit's nictitating membrane response is a function of the duration of dietary cholesterol

Modifying dietary cholesterol may improve learning and memory but very high cholesterol can cause pathophysiology and death. Rabbits fed 2% cholesterol for 8, 10 or 12 weeks with 0.12 ppm copper added to distilled water and rabbits fed a normal diet without copper added to distilled water (0 weeks) were given a difficult trace classical conditioning task and an easy delay conditioning task pairing tone with corneal air puff. The majority of cholesterol-fed rabbits survived the deleterious effects of the diet but survival was an inverse function of the diet duration. Compared to controls, the level of classical conditioning and conditioning-specific reflex modification were an inverted "U"-shaped function of diet duration. Highest levels of responding occurred in rabbits on cholesterol for 10 weeks and trace conditioning was negatively correlated with the number of hippocampal beta-amyloid-positive neurons. Rabbits on the diet for 12 weeks responded at levels comparable to controls. The data provide support for the idea that dietary cholesterol may facilitate learning and memory but there is an eventual trade off with pathophysiological consequences of the diet.

Recurrent lacunar infarction following a previous lacunar stroke: a clinical study of 122 patients

OBJECTIVE

To determine clinical variables related to recurrent lacunar infarction following a previous lacunar stroke.

METHODS

A total of 122 out of 733 consecutive patients with lacunar infarction collected from a hospital based registry between 1986 and 2004 were readmitted because of a recurrent lacunar infarction. In a subset of 59 patients, cognition was assessed using the Mini-Mental State Examination (MMSE). Predictors of lacunar infarction recurrence were assessed by logistic regression analysis.

RESULTS

First lacunar infarction recurrence occurred in 101 patients (83%) and multiple recurrences in 21. The mean time between first ever lacunar infarction and recurrent lacunes was 58.3 months (range 2-240). In the subset of 59 patients in whom cognition was studied, cognitive impairment, defined as an MMSE score <24, was detected in 16% (8/49) of patients with first lacunar infarction recurrence and in 40% (4/10) of those with multiple lacunar infarction recurrences. In the multivariate analysis, hypertension (odds ratio 2.01, 95% CI 1.23 to 3.30) and diabetes (odds ratio 1.62, 95% CI 1.07 to 2.46) were significant predictors of lacunar stroke recurrence, whereas hyperlipidaemia was inversely associated (odds ratio 0.52, 95% CI 0.30 to 0.90).

CONCLUSIONS

Hypertension and diabetes were significant factors related to recurrent lacunar infarction. Hyperlipidaemia appeared to have a protective role. Cognitive impairment was a frequent finding in patients with multiple lacunar infarction recurrences.

The APOE polymorphism and 1-year outcome in ischemic stroke: genotype-gender interaction

OBJECTIVE

In human genetic studies an effect of the apolipoprotein E gene (APOE) polymorphism on the risk, course and prognosis in chronic and acute nervous system disorders was established. We aimed to evaluate whether the APOE genotype is related to acute neurological impairments due to ischemic stroke (IS), and to outcomes (up to 1 year) indicated by severe functional disability, dependence in daily living or death.

MATERIALS AND METHODS

A total of 657 patients (326 men, 331 women), divided into the three groups: E2 (APOEepsilon2/epsilon3 subjects), E3 (APOEepsilon3/epsilon3 subjects), and E4 (APOEepsilon3/epsilon4 and epsilon4/epsilon4 subjects), were analyzed.

RESULTS

There was no association between the APOE genotype and baseline clinical characteristics, severity of neurological impairments during acute stroke, and 1-year outcome, when analyzing whole patient population. APOE gene interacted with gender in predicting severity of acute neurological deficit and post-stroke mortality within the period up to 1 year after the IS. Gender-stratified analysis indicated the E4 genotype as a significant independent positive predictor of death within 1 year after stroke incidence in men patients.

CONCLUSION

Ischemic stroke severity and outcome may be affected by complex interactions between gender and genetic factors that warrant further exploration.

Clustering of vascular risk factors and in-hospital death after acute ischemic stroke

OBJECTIVE

to evaluate the influence of clustering of vascular risk factors (VRF) on in-hospital mortality in patients with acute ischemic stroke (AIS) developing a risk score for mortality prediction.

METHODS

clinical data from 1527 patients admitted to hospital with a first-ever AIS were prospectively evaluated from 1997 to 2005 assessing the presence of six VRF: diabetes, hypertension, hyperlipidemia, ischemic heart disease, atrial fibrillation and peripheral arterial disease. A composite vascular risk score (VRS) was created using five risk factors. Hyperlipidemia was excluded from the score due to its protective impact on mortality. Two modified VRS models were created and assessed for their accuracy as predictors for in-hospital mortality based on the odds ratio for each VRF obtained in the univariate analysis.

RESULTS

197 patients (12.9 %) died during the acute hospitalization period. Stroke severity increased with each additional VRF (p = 0.002). Cox proportional hazards model adjusted for confounders showed an association between the composite VRS and in-hospital mortality (p = 0.045). According to the clustering of VRS, the risk for in-hospital death increased from 1.951 (95 % CI 1.041-3.665) for patients having one VRS to 2.343 (95% CI 1.081-5.076) for those having a VRS > or = 4. ROC curves showed that the modified VRS model based on a given value of one for each accumulated VRF, including the absence of hyperlipidemia, had the highest predictive capability for in-hospital mortality (p < 0.0001).

CONCLUSIONS

the presence of multiple VRF in patients with acute ischemic stroke increases the stroke severity and the risk of in-hospital death.

High dietary cholesterol facilitates classical conditioning of the rabbit's nictitating membrane response

Studies have shown that modifying dietary cholesterol may improve learning and that serum cholesterol levels can be positively correlated with cognitive performance. Rabbits fed a 0, 0.5, 1 or 2% cholesterol diet for eight weeks and 0.12 ppm copper added to their drinking water received trace and then delay classical conditioning pairing tone with corneal air puff during which movement of the nictitating membrane (NM) across the eye was monitored. We found that the level of classical conditioning and conditioning-specific reflex modification (CRM) as well as the number of beta amyloid-labeled neurons in the cortex and hippocampus were a function of the concentration of cholesterol in the diet. The data provide support for the idea that dietary cholesterol may facilitate learning and memory.

Higher total serum cholesterol levels are associated with less severe strokes and lower all-cause mortality: ten-year follow-up of ischemic strokes in the Copenhagen Stroke Study

BACKGROUND AND PURPOSE

Evidence of a causal relation between serum cholesterol and stroke is inconsistent. We investigated the relation between total serum cholesterol and both stroke severity and poststroke mortality to test the hypothesis that hypercholesterolemia is primarily associated with minor stroke.

METHODS

In the study, 652 unselected patients with ischemic stroke arrived at the hospital within 24 hours of stroke onset. A measure of total serum cholesterol was obtained in 513 (79%) within the 24-hour time window. Stroke severity was measured with the Scandinavian Stroke Scale (0=worst, 58=best); a full cardiovascular risk profile was established for all. Death within 10 years after stroke onset was obtained from the Danish Registry of Persons.

RESULTS

Mean+/-SD age of the 513 patients was 75+/-10 years, 54% were women, and the mean+/-SD Scandinavian Stroke Scale score was 39+/-17. Serum cholesterol was inversely and almost linearly related to stroke severity: an increase of 1 mmol/L in total serum cholesterol resulted in an increase in the Scandinavian Stroke Scale score of 1.32 (95% CI, 0.28 to 2.36, P=0.013), meaning that higher cholesterol levels are associated with less severe strokes. A survival analysis revealed an inverse linear relation between serum cholesterol and mortality, meaning that an increase of 1 mmol/L in cholesterol results in a hazard ratio of 0.89 (95% CI, 0.82 to 0.97, P=0.01).

CONCLUSIONS

The results of our study support the hypothesis that a higher cholesterol level favors development of minor strokes. Because of selection, therefore, major strokes are more often seen in patients with lower cholesterol levels. Poststroke mortality, therefore, is inversely related to cholesterol.

Serum Uric Acid as an Independent Predictor of Early Death After Acute Stroke

BACKGROUND

The prognostic significance of uric acid (UA) levels in acute stroke is unclear, so the objective of this study was to determine the association between levels of serum UA (SUA) and mortality in acute stroke.

METHODS AND RESULTS

Consecutive patients (n=435) presenting with ischemic stroke and intracerebral hemorrhage were included in the study. The length of stay in hospital and the occurrence of death were recorded. On univariate analysis, the occurrence of death was associated with older age, smoking, presence of congestive heart failure or atrial fibrillation, absence of hyperlipidemia, and intracerebral hemorrhage as the index event. Furthermore, glucose, urea, creatinine and SUA at admission were significantly higher in patients who died, whereas total and high-density-lipoprotein cholesterol were significantly lower. On multiple logistic regression analysis, the independent relationship between higher SUA levels and death was confirmed (odds ratio (OR), 1.37; 95%confidence interval (CI), 1.13-1.67; p=0.001). The only other variables independently associated with the occurrence of death were urea concentration and presence of atrial fibrillation. If urate was >7.8 mg/dl (0.47 mmol/L), then there would be a high probability of early death (87%).

CONCLUSIONS

Elevated levels of SUA are independently associated with an increased risk of early death in acute stroke.

Vascular endothelial growth factor improves recovery of sensorimotor and cognitive deficits after focal cerebral ischemia in the rat

Vascular endothelial growth factor (VEGF) is an angiogenesis factor with neurotrophic, neuroprotective and neuroproliferative effects. Depending on the dose, route and time of administration in relation to focal cerebral ischemia, VEGF can improve histological outcome and sensorimotor function in rodents. However, VEGF also increases vascular permeability, which can lead to brain edema and exacerbate ischemic brain injury. Thus, although VEGF is a candidate therapeutic for stroke and other ischemic disorders, its benefit relative to risk is uncertain. Considering that functional rather than histological measures of outcome are probably most relevant to therapeutic prospects for human stroke, we investigated the effects of VEGF after middle cerebral artery occlusion in rats using a series of behavioral tests. We report that VEGF improves functional outcome in ischemic rats, including both sensorimotor and cognitive deficiencies.

Early cognitive impairment predicts long-term depressive symptoms and quality of life after stroke

OBJECTIVE

The aim of the present study was to examine the predictive value of cognitive impairment in the acute phase after stroke as a risk factor for long-term (six to ten months after stroke) depressive symptoms (DS) and a reduced quality of life (QOL), independent of demographic and neurological predictors.

METHODS

We evaluated 143 patients within the first 3 weeks post-stroke. Predictor variables included domain-specific cognitive function, demographic data, vascular risk factors, lesion characteristics, and clinical factors. Predictor variables associated with long-term DS (Montgomery Asberg Depression Rating Scale >or=7) and QOL (Stroke-Specific Quality of Life Scale) were identified with multiple logistic and linear regression.

RESULTS

Long-term DS were independently predicted by cognitive impairment at baseline, DS at baseline, female sex, diabetes mellitus, and previous TIA(s). Cognitive impairment, increasing age, and functional dependence predicted a reduced QOL, whereas hypercholesterolaemia predicted a better QOL. Among all cognitive disorders, unilateral neglect was the greatest risk factor for DS after 6 months, whereas a disorder in visual perception and construction affected QOL the most.

CONCLUSIONS

Cognitive impairment and vascular risk factors are important predictors of long-term DS and QOL after stroke. The prognostic value of cognition suggests a reactive component in the development or continuation of long-term DS.

Effects of Policosanol on Patients with Ischemic Stroke: A Pilot Open Study

Stroke is a major health problem worldwide. Its pharmacological management includes thrombolytic therapy for the acute phase and antiplatelet drugs for stroke recovery and prevention. Statins can help in the acute phase and in preventing stroke in secondary prevention patients. Policosanol is a cholesterol-lowering drug with concomitant antiplatelet effects, with protective effects in stroke models. This observational study investigated the effects of policosanol (20 mg/day) administered during the acute phase and for 5 years later on the neurological recovery of patients with ischemic stroke treated with antiplatelets and vitamins. After hospital discharge, patients were followed up every 3 (first year) and 6 (thereafter) months. Neurological improvement was assessed with the modified Canadian Neurological Scale. Adverse events were recorded. Fifty patients were included; all completed the study. Neurological score improved throughout the study. No patient died, and most [40 (80.0%)] did not experience new vascular events; only one (2.0%) suffered a new stroke, and two (4.0%) suffered more than one transient ischemic attack. The time to the first recurrent event was 46.2 months. Policosanol persistently lowered serum total cholesterol, with such reduction correlating with the neurological improvement (R = 0.995253301). Triglycerides were unchanged. Treatment was well tolerated. Policosanol administered to patients suffering ischemic stroke treated with aspirin and vitamins showed good results on neurological outcomes and recurrent events. This study, however, has limitations, since it was open and uncontrolled, and patients also consumed aspirin and vitamins. New randomized, controlled studies are needed to assess the usefulness of policosanol in stroke management.

Early poststroke seizures

We define as early seizure (ES) those occurring within 7 days after stroke and late seizures those developing beyond 1 week after stroke. Seizures are well known to occur at the onset of intracerebral hemorrhage and serve as a clinical marker. Onset seizures may be focal or generalized, are usually brief and are associated with loss of consciousness in the setting of hemorrhage. A similar concept of immediate seizure occurs in traumatic brain injury. Predictive factors of ES can be classified of general and neurologic origin. An important question is whether ES per se worsen prognosis and outcome. The viability of the penumbral region in animal models of focal ischemia is influenced by the peri-infarct depolarization waves. If this also is true in humans, seizures in the immediate poststroke period might worsen outcome. Recently, hypercholesterolemia has been associated with better functional outcome at 1 month after a first-ever stroke, and multivariate analysis studies have shown that mean cholesterol values were lower in patients with ES compared with controls.

Trends in Lipid Management Among Patients with Diabetes

OBJECTIVE

To examine trends in lipid management (cholesterol testing, treatment, and goal attainment) among patients with diabetes and to analyze the factors associated with initiation of lipid-lowering therapy.

METHODS

We conducted a longitudinal, retrospective study of patients with diabetes identified during a 24-month baseline period (January 1, 1995, to December 31, 1996) and for whom follow-up was continued for 5 years (1997 to 2001). Generalized estimating equations were used to test for time trend effects in lipid management. We modeled the days from baseline to the first lipid-lowering prescription fill date with a multivariate Cox proportional hazards regression model.

RESULTS

Rates of lipid testing, treatment, and goal attainment significantly improved (P<0.001) during the 5-year study period: from 37% to 67% for lipid testing; from 19% to 41% for treatment with a lipid-lowering agent; from 22% to 37% for achievement of low-density lipoprotein cholesterol (LDL-C) levels < 100 mg/dL; and from 54% to 75% for achievement of LDL-C levels < 130 mg/dL. The relative likelihood (hazard rate) of treatment with lipid-lowering agents was greater for patients with LDL-C levels > or = 100 mg/dL relative to patients with LDL-C concentrations < 100 mg/dL. Treatment with lipid-lowering agents of patients with a cardiovascular event during follow-up was approximately 3 times more likely relative to those without such an event.

CONCLUSION

We found that rates of lipid testing, treatment, and goal attainment improved significantly between 1997 and 2001. Nevertheless, ample room for improvement of these rates continues to exist. Particular attention may be warranted to ensure that patients with diabetes receive lipid-lowering agents not only after a cardiovascular event but also before such an event occurs.

Total Serum Cholesterol and Recovery From Disability Among Hospitalized Older Adults

BACKGROUND

The association between total serum cholesterol and health outcomes among older adults is controversial. The objective of the present study was to determine within a cohort of acutely hospitalized disabled elderly patients whether total cholesterol predicts recovery from disability in basic activities of daily living (ADL).

METHODS

Patients (3150) 65 years old or older admitted to 81 acute care units in Italy and presenting with ADL disability at hospital admission were included in this study. ADL disability was defined as need of assistance or total dependence in one or more ADLs (eating, dressing, personal hygiene, transferring, and toilet use). Recovery was defined as no disability at hospital discharge in any of the five ADLs considered.

RESULTS

Mean age of study participants was 80.5 +/- 7.2 years, and 1305 (41.1%) were men. The rate of recovery from ADL disability was 14.5% for participants with total cholesterol < 200 mg/dL (n = 306/2108), 20.2% for those with total cholesterol between 200 and 239 mg/dL (n = 144/713), and 23.1% for those with total cholesterol > or = 240 mg/dL (n = 76/329). After adjustment for potential confounders, relative to that of patients with cholesterol < 200 mg/dL, risk ratios for recovery were 1.31 for participants with cholesterol between 200 and 239 mg/dL (95% confidence interval [CI], 1.07-1.62) and 1.36 (95% CI, 1.04-1.79) for those with cholesterol > or = 240 mg/dL. After exclusion of 769 patients with total cholesterol < 145 mg/dL, the risk ratios (compared with those for participants with cholesterol < 200 mg/dL) for recovery were 1.33 (95% CI, 1.07-1.66) for participants with cholesterol between 200 and 239 mg/dL and 1.41 (95% CI, 1.06-1.88) for patients with cholesterol > or = 240 mg/dL.

CONCLUSIONS

Among hospitalized disabled older adults, elevated levels of cholesterol are associated with increased rate of recovery from ADL disability.

Hypercholesterolemia Enhances Tolerance to Lethal Systemic Hypoxia in Middle-Aged Mice: Possible Role of VEGF Downregulation in Brain

Hypercholesterolemia (HCL) is commonly associated with impaired vascular relaxation response and augmented vasoconstriction. Interestingly, it was shown that animals with HCL were less vulnerable to seizures and several clinical studies also revealed a better outcome after stroke in the patients with HCL. To this context, the present study was designed to test the hypothesis that HCL would enhance the animals' resistance to severe systemic hypoxia and in turn prolong their survival time under such noxious condition. Four groups of middle-aged (mean age: 51.1 +/- 2.8 weeks) male C57BL/6J wild-type mice (C57BL-WT) and low-density lipoprotein receptor knockout mice (LDLR-KO) were included in the study: two groups were exposed to severe normobaric hypoxia (5% F(I)O(2)) and other two groups were used for brain tissue sample collection and Western blot analysis. The survival time under the hypoxic condition was recorded for each animal. Individual blood samples were collected immedtately after the cessation of spontaneous breathing for measuring plasma total cholesterol (TCL) and triglycerides. The results show that the hypoxia survival time was longer in LDLR-KO than C57BL-WT (i.e. 3.7 +/- 0.5 versus 2.3 +/- 0.2 min; P < 0.05). A positive correlation was found between TCL and the survival time (r (2) = 0.43; P < 0.05). Furthermore, a significant downregulation of vascular endothelial growth factor (VEGF) was observed in the brain tissue of LDLR-KO, as compared with C57BL-WT (n, = 3/group; P < 0.05), whereas expression of heme oxygenase 1 was similar in these two groups. We conclude that HCL enhances resistance to lethal systemic hypoxia (i.e. 61% increase in survival time) in middle-aged mice. This paradoxical protective effect of HCL was associated with a concomitant downregulation of cerebral VEGF expression, which could potentially blunt the hypoxia-triggered and VEGF-mediated pathophysiological events leading to death.

Clinical laboratory findings associated with in-hospital mortality

The diagnostic approach and the clinical management of critically ill patients is challenging. The recognition of biomarkers related to in-hospital mortality is of importance for identification of patients at increased risk of death. Many prediction models assessing the severity of illness and likelihood of hospital survival were developed using logistic regression analyses. These models include several laboratory parameters, such as white blood cell counts, serum bilirubin, serum albumin, blood glucose, serum electrolytes and markers which reflect acid-base disturbances. Recently, several other biomarkers, including troponin, B-type natriuretic peptide (BNP), N-terminal proBNP, C-reactive protein, procalcitonin, cholesterol and coagulation related markers have emerged as clinically useful tools for risk stratification and mortality prediction of heterogeneous and more specific subgroups of critically ill patients. More investigations are required to verify whether risk stratification based on mortality-related biomarkers may translate into targeted treatment strategies to improve clinical outcome of the critical illness. Biomarkers which are related to in-hospital mortality are highlighted in the current review.

Clinical characteristics of first-ever atherothrombotic infarction or lacunar infarction with hyperlipidemia (J-STARS-C): an analysis of data from the stroke data bank of Japan

OBJECTIVE

The clinical trial, Japan Statin Treatment Against Recurrent Stroke (J-STARS), is being carried out to investigate the efficacy of statin treatment against recurrent stroke. To participate in J-STARS, patients must have a past history of ischemic stroke excluding cardioembolic events, and must be clinically diagnosed with hyperlipidemia (HL). Before starting J-STARS, we needed to be aware of the clinical characteristics of the patients who were eligible to participate in this study.

METHODS

Between 1999 and 2002, 7,149 patients with ischemic stroke were enrolled in a stroke data bank developed by the Japan Standard Stroke Registry Study Group. From this, we acquired the data on 1,487 patients with first-ever atherothrombotic infarction (ATI) or lacunar infarction (LI) with a satisfactory functional outcome on discharge.

RESULTS

Patients with HL were significantly younger (65.3+/-11.0 vs 68.4+/-10.9, p<0.0001) and showed a higher frequency of concomitant hypertension (70.9% vs 61.0%, p=0.0002), diabetes mellitus (42.2% vs 25.7%, p<0.0001) or both (31.7% vs 16.4%, p<0.0001) compared to those without HL. The ratio of ATI to LI and the frequency of prior ischemic heart disease (IHD) did not differ between the 2 groups. Among 467 patients with HL, 52.7% did not receive treatment on admission.

CONCLUSION

ATI or LI patients with HL had an earlier age of onset and higher frequency of other lifestyle-related diseases, and this probably includes many with metabolic syndrome, whereas the frequency of IHD was not different between these 2 groups.

Statins and stroke

Inhibitors of HMG-CoA reductase (statins) are potent cholesterol-lowering drugs. Large clinical trials have shown that statins reduce the incidence of cerebrovascular events, which might be surprising because cholesterol is not an established risk factor for stroke. In addition to their cholesterol-lowering properties, statins exert a number of pleiotropic, vasculoprotective actions that include improvement of endothelial function, increased nitric oxide (NO) bioavailability, antioxidant properties, inhibition of inflammatory responses, immunomodulatory actions, regulation of progenitor cells, and stabilization of atherosclerotic plaques. In fact, statins augment cerebral blood flow and confer significant protection in animal models of stroke partly via mechanisms related to the upregulation of endothelial nitric oxide synthase. Retrospective clinical evidence suggests that long-term statin administration may not only reduce stroke risk but also improve outcome. Early secondary prevention trials are underway to test the hypothesis that statin treatment initiated immediately after an event improves short-term outcome. Lastly, recent evidence suggests that sudden discontinuation of statin treatment leads to a rebound effect with downregulation of NO production. Withdrawal of statin treatment may impair vascular function and increase morbidity and mortality in patients with vascular disease.

APOE genotype and serum cholesterol in predicting risk for early death from ischemic stroke in men and women

BACKGROUND

We recently discovered that APOE epsilon3/epsilon4 genotype in men and APOE epsilon2/epsilon3 genotype in women are associated with increased risk of death from ischemic stroke (IS). One of the main physiological roles of apolipoprotein E is participation in cholesterol metabolism. A significant association of low serum cholesterol level with increased risk of death from stroke was documented. So, we aimed to establish if an association exists between APOE genotype, serum cholesterol and 1-month mortality in IS.

METHODS

We studied 666 patients (330 men, 336 women) with a diagnosis of IS. Total serum cholesterol (TC) was measured with the method of Abbott Spectrum (USA). APOE genotyping was performed by PCR-RFLP method.

RESULTS

The highest frequency of low serum TC was associated with APOE epsilon2/epsilon3 genotype (both in men and in women). Low serum TC was associated with increased mortality rate only in women; this effect was evident only in females not possessing APOE epsilon2/epsilon3. Female patients with APOE epsilon2/epsilon3 genotype had high 1-month mortality rate independently from serum TC. In multiple regression analyses APOE epsilon3/epsilon4 genotype in men and APOE epsilon2/epsilon3 genotype in women predicted risk of death independently from serum TC and also from other potential pre- and post-stroke prognostic factors.

CONCLUSION

APOE epsilon3/epsilon4 genotype in men and APOE epsilon2/epsilon3 in women are associated with increased 30-day mortality in stroke. This effect seems be independent from serum cholesterol.

Outcome in patients with stroke associated with internal carotid artery occlusion

BACKGROUND

The clinical outcome in patients with stroke associated with internal carotid artery (ICA) occlusion is poor, although a minority may recover without dependency. The purposes of this study were (1) to assess the predictive factors of adverse outcome in patients with stroke associated with an occlusion of the ICA and (2) to evaluate the rate of spontaneous recanalization of an occluded ICA.

METHODS

A total of 177 consecutive patients with first-ever ischemic stroke associated with ICA occlusion were prospectively examined from the Perugia Stroke Registry. Mean age was 71.4 +/- 14.3 years; 53% were males. Multiple regression models were used to analyze predictors of mortality, dependency and ipsilateral stroke recurrence.

RESULTS

The most probable cause of occlusion was atherosclerosis in 65%, cardioembolism in 22%, dissection in 9% and other causes in 4%. Thirty percent of the patients died within 30 days. After a mean follow-up of 420 days (range 1-1,970 days), 45% of the patients had died and 75% had died or were disabled. Another 6% of the patients had a recurrent stroke ipsilateral to the occluded carotid artery. Age was the only predictor of 30-day mortality (77.7 +/- 9.7 vs. 68.7 +/- 15.2 years; p = 0.03) and of long-term mortality or disability (p < 0.003). Hypertension (OR 0.42; 95% CI 0.17-1.00; p = 0.05) was associated with a better outcome within 30 days from stroke onset. Previous ipsilateral transient ischemic attack (OR 0.24; 95% CI 0.06-0.89; p = 0.03) and hyperlipidemia (OR 0.38; 95% CI 0.15-0.99; p = 0.049) were predictors of a better outcome with respect to long-term mortality or disability. No predictors of ipsilateral stroke recurrence were found. One hundred and five out of 177 patients had adequate follow-up ultrasound data. After a mean follow-up of 1.8 years, 10 patients had recanalization of the occluded ICA (2/71 atherosclerosis, 3/19 cardioembolism and 5/15 dissection).

CONCLUSIONS

After a mean follow-up of 1.2 years, 45% of the patients with stroke associated with ICA occlusion had died, while 75% had died or were functionally dependent. The presence of either previous ipsilateral transient ischemic attack, hypertension or hyperlipidemia was associated with a favorable outcome. Recanalization of an occluded ICA occurred in a minority of patients and it was associated with cardioembolism and with arterial dissection.

Does cholesterol act as a protector of cholinergic projections in Alzheimer's disease?

The relationship between Alzheimer's disease (AD) and progressive degeneration of the forebrain cholinergic system is very well established, whereas mechanisms linking this disease with cholesterol, apolipoprotein E (apoE) phenotype, and amyloid precursor protein (APP) metabolism have not been fully elucidated even though there is a plethora of publications separately on each of these issues. The intention of this hypothesis is to unify knowledge coming from all of these areas. It is based on an assumption that the process of APP hypermetabolism is a neuroprotective response for age-related cholinergic deterioration. In some individuals this initially positive process becomes highly overregulated by genetic or/and epigenetic risk factors and after many years of accumulations lead eventually to AD. I hypothesise that neuroprotective role of APP-hypermetabolism might be related to enrichment of neuronal membranes (lipid rafts in particular) in cholesterol in order to compensate for decrease in presynaptic cholinergic transmission and/or AD-related decrease in cholesterol levels. The above is consistent with findings indicating that activity of both muscarinic and nicotinic cholinergic receptors is correlated in a positive manner with cholesterol plasmalemmal content. Briefly – APP metabolism together with transport of cholesterol in apoE containing lipoproteins seem to play a key role in mobilising cholesterol into neuronal membranes.

Long-term prognosis of ischemic stroke in young adults. Study of 272 cases

BACKGROUND

There have been few studies of the long-term prognosis of young adults with ischemic stroke. The present study aimed to evaluate the long-term clinical outcome in a large series of young adults with ischemic stroke admitted to a tertiary medical center over the last 27 years, and to identify possible predictors for mortality, stroke recurrence and poor functional recovery.

METHODS

We retrospectively reviewed 272 young adults (15-45 years) with a first-ever ischemic stroke admitted to the Neurology Department of University Hospital "12 de Octubre" between 1974 and 2001. Follow-up assessments were performed by review of medical records and telephone interviews.

RESULTS

Nine patients (3%) died as the result of their initial stroke and follow-up information about the status of 23 (8%) patients was not available. The remaining 240 patients (89%) were followed. Two hundred and ten of them (88%) were alive with a mean follow-up of 12.3 years and 30 (12%) died during follow-up. The average annual mortality rate was 1.4%, being notably higher during the first (4.9%) than in the subsequent years (0.9%) after the initial stroke. Ninety per cent of the followed patients were independent and 53% returned to work, although adjustments were necessary for 23% of them. The annual stroke recurrence rate during the first year was 3.6% dropping to 1.7% in subsequent years. Age over 35 years, male gender, the presence of cardiovascular risk factors and large-artery atherosclerosis in the carotid territory were predictors of negative long-term outcome after the initial stroke.

CONCLUSIONS

The long-term prognosis for the ischemic stroke in the young is better than in the elderly, but the risk of mortality in young adults with ischemic stroke is much higher than in the general population of the same age. A bad prognosis is associated with an atherosclerotic risk profile, with a higher mortality and recurrent stroke rates and poorer functional recovery. The main functional limitation in the young survivors of their initial ischemic stroke occurs in work activity, since most patients are independent but almost half of them do not return to work.

Plasma homocysteine level and functional outcome of patients with ischemic stroke

OBJECTIVE

To investigate the possible relationships between total plasma homocysteine level (tHcy) and functional outcome of stroke patients as evaluated by the FIM instrument.

DESIGN

Retrospective chart analysis.

SETTING

Inpatient stroke rehabilitation ward of a university-affiliated referral hospital.

PARTICIPANTS

Consecutive patients (N=113) presenting with acute ischemic stroke. Patients were divided into 2 groups according to their tHcy levels (< or = 15 micromol/L, >15 micromol/L) and into 3 groups according to their FIM scores (low, < or =40; moderate, 41-80; high, >80).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The tHcy level was determined shortly after stroke onset by a high performance liquid chromatography method with fluorescence detection. Functional outcome was measured by the FIM instrument at admission and discharge. The tHcy level and FIM scores were obtained for all patients. Data outcomes were analyzed by t tests, 1-way analysis of variance, Mann-Whitney U, and Fisher exact tests, as well as by the 2 ordered polytomous logistic regression model.

RESULTS

The 2 tHcy groups were similar in demographic, stroke, and comorbidity characteristics, differing only by higher frequency of hypertension in those with a tHcy greater than 15 micromol/L (51.7% vs 80.8%, respectively, P=.01). Compared with patients who had tHcy levels at 15 micromol/L or lower and were discharged from rehabilitation being in the highest FIM score group (>80), higher tHcy levels were not associated with a discharge FIM score of less than 40 (odds ratio [OR]=.77; 95% confidence interval [CI], 0.13-4.65; P=.77) or with a better functional outcome FIM score between 40 and 80 (OR=3.71; 95% CI, 0.73-18.99; P=.11).

CONCLUSIONS

Our findings suggest that determination of tHcy level does not correlate with functional outcome in patients presenting for rehabilitation after acute ischemic stroke.

Hypercholesterolemic diet applied to rat dams protects their offspring against cognitive deficits. Simulated neonatal anoxia model

There is accumulating data suggesting a neuroprotective activity of cholesterol, especially in stroke and Alzheimer's disease (AD). In the present study, a protective activity of this lipid in simulated neonatal anoxia was investigated. Rats were subjected to high cholesterol by feeding their dams with a diet enriched with cholesterol. Half of these rats were subjected to anoxia. One and a half months later, the rats were tested for their ability to acquire a spatial memory, one group on the linear maze and the other on the Morris water maze. After these assessments, the level of total plasma cholesterol was measured. Rats from dams subjected to neonatal anoxia on standard diet performed worse than control rats in both types of behavioral experiments, whereas anoxic rats from dams were housed on hypercholesterolemic diet performed as control animals. It suggests that dietetic cholesterol applied by their dams protected rats against cognitive deficits elicited by neonatal anoxia. Furthermore, offspring of anoxic rats housed on standard diet had elevated levels of blood cholesterol in relation to control animals. Generally, anoxia affected the concentration of this lipid much stronger than hypercholesterolemic diet of their dams. It might mean that the anoxia-related rise of cholesterol could be involved in physiological phenomenon being an adaptive response to neurotoxic processes. This concept is discussed in relation to pathological mechanisms in AD.

Stroke patterns, etiology, and prognosis in patients with diabetes mellitus

BACKGROUND

Although diabetes mellitus (DM) is a risk factor for stroke, it is unclear whether stroke features are different in diabetic vs nondiabetic individuals.

OBJECTIVE

To assess the role of DM in stroke patients.

METHODS

Risk factors, etiology, lesion topography, clinical features, and outcome were assessed in 611 diabetic individuals (history of DM or fasting plasma glucose level of > or =7.0 mmol/L) among 4,064 consecutive patients of the Lausanne Stroke Registry.

RESULTS

Patients with DM were 5.3 years older than non-DM patients. After multivariate analysis, DM was associated with lower relative prevalence of intracerebral hemorrhage (ICH; odds ratio [95% CI]: 0.63 (0.45 to 0.9); p = 0.022), higher relative prevalence of subcortical infarction (SCI; 1.34 [1.11 to 1.62]; p = 0.009), and higher relative frequency of small-vessel (SVD; 1.78 [1.31 to 3.82]; p = 0.012) and large-artery (LAD; 2.02 [1.31 to 2.02]; p = 0.002) disease. In the cohort of diabetic stroke patients, there was no interaction of DM with either hypertension or age for the outcomes of ICH, SCI, SVD, and LAD. Moderate to severe deficit on admission (31.1 vs 31.6%; p = 0.4) and poor functional outcome at 1 month (14.1 vs 15.3%; p = 0.24) did not differ in patients with DM compared with non-DM patients. In multivariate analysis, neither DM (0.86 [0.63 to 1.11]; p = 0.15) nor hypertension (1.09 [0.91 to 1.39]; p = 0.32) was associated with poor functional outcome.

CONCLUSIONS

Diabetic stroke patients are associated with specific patterns of stroke type, etiology, and topography but not with poor functional outcome. There was no interaction between DM and hypertension or age.

Effect of pretreatment with statins on the severity of acute ischemic cerebrovascular events

OBJECTIVE

Treatment with statins reduces the risk of ischemic stroke among patients at increased risk for vascular disease. Recent experimental data suggest neuroprotective properties of statins in acute cerebral ischemia. We investigated whether a premedication with statins is associated with a better outcome in patients with acute ischemic cerebrovascular events.

METHODS

Within a cross-sectional study, nested in a cohort we identified 1691 patients with a recent ischemic stroke or transient ischemic attack. Clinical severity of the vascular event was evaluated by the modified Rankin Scale (mRS) after 1 week. By means of multivariate logistic regression modeling, we determined the influence of prior statin use on stroke severity with adjustment for potential confounding factors.

RESULTS

Severe stroke, defined as a modified Rankin Scale of 5 or 6 (n=231; 14%), was less frequent in patients receiving statin treatment before the event (6% vs. 14%, OR=0.37; 95% CI 0.19 to 0.74; p=0.004). This association remained significant after adjustment for confounding factors. We found a significant interaction between the presence of diabetes and the effect of pretreatment with statins on stroke outcome. Of the patients with diabetes, none of those on statin treatment but 16% of those without a statin had a bad outcome. After exclusion of the group of diabetic patients with prior statin medication, the protective effect was reduced and not statistically significant anymore.

CONCLUSIONS

Pretreatment with statins seems to be associated with reduced clinical severity in patients with acute ischemic cerebrovascular events, particularly in patients with diabetes.

Lower Serum Triglyceride Level Is Associated With Increased Stroke Severity

BACKGROUND AND PURPOSE

A previous study showed that low triglyceride concentration predicts higher mortality after stroke. The aim of our study was to determine whether serum triglyceride level is associated with stroke severity on admission.

METHODS

863 consecutive patients with acute ischemic stroke were included. Serum triglyceride level was measured within 36 hours after stroke onset. Stroke severity on admission was assessed using Scandinavian Stroke Scale (SSS). The patients were divided into 2 groups: those with severe stroke (SSS < or =25) and those with mild/moderate stroke (SSS >25).

RESULTS

Patients with severe stroke had significantly lower serum triglyceride level than patients with mild/moderate stroke (1.4+/-0.6 versus 1.7+/-1.3 mmol/L). After adjusting for age, sex, atrial fibrillation, diabetes mellitus, obesity, and ischemic heart disease, patients with triglyceride >2.3 mmol/L had lower risk of severe stroke than those with triglyceride < or =2.3 mmol/L (OR: 0.58; 95% CI: 0.35 to 0.95).

CONCLUSIONS

Our results suggest that lower level of triglyceride is associated with the more severe stroke.

Low cholesterol levels are associated with short-term mortality in older patients with ischemic stroke

BACKGROUND

The possible relationship between serum total cholesterol (TC) levels and outcome following ischemic stroke is still controversial. We evaluated the association between TC levels and 30-day mortality in a sample of older patients with acute ischemic stroke.

METHODS

We enrolled 490 older patients with severe ischemic stroke consecutively admitted to University Hospital's Internal Medicine or Geriatrics Department. Stroke type was classified according to the Oxfordshire Community Stroke Project. The data recorded included clinical features, medical history, electrocardiogram, and blood analyses. Patients were divided into three groups by TC levels: group I (TC<4.1 mmol/L), group II (TC 4.1-5.2 mmol/L), and group III (TC>5.2 mmol/L).

RESULTS

The overall mortality was 27.7%. Mortality was higher in patients with low TC levels (47.4%) compared with those with normal and high TC levels (23.0% and 24.1%, respectively). The odds ratio (OR) for short-term death was 2.17 (95% confidence interval [CI] 1.22-3.85) in group I compared with group III, after adjustment for age and gender. This result did not change after adjustment for possible confounders (OR 2.87; 95% CI 1.23-6.68). A similar trend was observed after adjustment for the Oxfordshire classification, age, and gender (OR 1.67; 95% CI 0.83-3.33).

CONCLUSIONS

Short-term mortality following ischemic stroke is higher in older participants with low TC levels, independent of a large number of factors. Low TC levels might be useful in identifying frail older participants at high risk of stroke short-term mortality.

Increases in serum non-high-density lipoprotein cholesterol may be beneficial in some high-functioning older adults: MacArthur studies of successful aging

objectives: To examine the association between changes in serum non-high-density lipoprotein cholesterol (non-HDL-C) over a 2.5-year period and risk of adverse health outcomes in the following 4.5 years in high-functioning older adults.

DESIGN

Prospective cohort, established in 1988, with a follow-up in 1991 and 1995.

SETTING

Population-based, community-dwelling men and women.

PARTICIPANTS

A random sample (n=267) from the MacArthur cohort (N=1,189). The cohort represented the highest-functioning tertile of 4,030 screened candidates aged 70 to 79.

MEASUREMENTS

Change in non-HDL-C between 1988 and 1991 was measured as a predictor of health outcomes between 1991 and 1995, including all-cause mortality, and among survivors, incident heart attack or stroke, development of new disability in basic activities of daily living, and decline in performance on the Short Portable Mental Status Questionnaire.

RESULTS

More-positive change in non-HDL-C between 1988 and 1991 was associated with fewer adverse outcomes between 1991 and 1995. In individuals whose total cholesterol at baseline was in the middle two quartiles (195-244 mg/dL), each 10-mg/dL increase in the 1988-to-1991 change in non-HDL-C was associated with an adjusted mortality odds ratio (OR) of 0.67 (95% confidence interval (CI)=0.51-0.88). In individuals without cardiovascular disease at baseline, the adjusted OR for new physical disability was 0.79 (95% CI=0.65-0.95) and for cognitive decline was 0.81 (95% CI=0.67-0.98).

CONCLUSION

Increases in cholesterol over time have beneficial associations in some older adults. The role of cholesterol changes in the health of older individuals needs further exploration.

Favorable Outcome of Ischemic Stroke in Patients Pretreated with Statins

Background and Purpose— Statins may be beneficial for patients with acute ischemic stroke. We tested the hypothesis that patients pretreated with statins at the onset of stroke have less severe neurological effects and a better outcome.

Methods— We prospectively included consecutive patients with ischemic stroke of <24-hour duration. We recorded demographic data, vascular risk factors, Oxfordshire Classification, National Institutes of Health Stroke Scale (NIHSS) score, admission blood glucose and body temperature, cause (Trial of Org 10172 in Acute Treatment [TOAST] criteria), neurological progression at day 3, previous statin treatment, and outcome at 3 months. We analyzed the data using univariate methods and a logistic regression with the dependent variable of good outcome (modified Rankin Scale [mRS] 0 to 1, Barthel Index [BI] 95 to 100).

Results— We included 167 patients (mean age 70.7±12 years, 94 men). Thirty patients (18%) were using statins when admitted. In the statin group, the median NIHSS score was not significantly lower and the risk of progression was not significantly reduced. Favorable outcomes at 3 months were more frequent in the statin group (80% versus 61.3%, P =0.059 with the mRS; 76.7% versus 51.8%, P =0.015 with the BI). Predictors of favorable outcome with the BI were: NIHSS score at admission (OR: 0.72; CI: 0.65 to 0.80; P <0.0001), age (OR: 0.96; CI: 0.92 to 0.99; P =0.017), and statin group (OR: 5.55; CI: 1.42 to 17.8; P =0.012).

Conclusions— Statins may provide benefits for the long-term functional outcome when administered before the onset of cerebral ischemia. However, randomized controlled trials will be required to evaluate the validity of our results.

Apolipoprotein E epsilon4 and the risk of unfavorable outcome after aneurysmal subarachnoid hemorrhage

BACKGROUND

The APOE-E4 allele has been identified as a risk factor for Alzheimer's disease and unfavorable outcomes after brain injuries. The purpose of this study was to confirm that APOE allele polymorphism also represents a risk factor for unfavorable outcomes following aneurysmal subarachnoid hemorrhage (SAH).

METHODS

A total of 104 patients with aneurysmal SAH were studied. Computed tomography (CT) scan findings of SAH were assessed by Fisher's grade and clinical neurologic assessment was performed using the Hunt and Hess (H&H)grading system. Serum lipids were also analyzed. Outcomes at 3 months after SAH were determined using the Glasgow Outcome Scale.

RESULTS

The distributions of APOE genotypes and alleles of patients were matched with those of control subjects. That 5 of 18 patients with APOE-E4 allele (28%) had an unfavorable outcome was significantly different from those without APOE-E4 (8%, chi2, p = 0.032; OR = 4.34, 95% CI 1.20-15.75). However, the presence or absence of E2 or E3 alleles had no significant difference. The relative hazard of APOE-E4 for unfavorable outcome exited after adjustment for clinical assessment (OR = 6.95, 95% CI 1.21-39.75). Total serum cholesterol, low-density lipoprotein and apolipoprotein B were elevated in patients with unfavorable rather than favorable outcomes.

CONCLUSION

Our findings confirmed that the patients with APOE-E4 allele were predisposed to unfavorable outcomes after aneurysmal SAH even though an association between APOE and incidence of the SAH may not exist. The effect of APOE on neurobiology and lipoprotein metabolism seems to partially explain the difference in outcomes and deserves further study.

Nutritional assessment in the hospitalized patient

PURPOSE OF REVIEW

Malnutrition is highly prevalent in hospitalized patients. Despite this, it is not routinely assessed in most hospitals worldwide. One of the reasons that might explain this fact is that there is no gold-standard nutritional assessment tool, and much has been written advocating this or that technique. The main topic of this review is discussion of the advantages and disadvantages of each of the available tools.

RECENT FINDINGS

Several studies have recently reinforced the relationship between poor nutritional status and higher incidences of complications, mortality, length of hospital stay and costs. Therefore, it is of the utmost importance to be able to diagnose malnutrition early.

SUMMARY

The evaluation of nutritional status is a broad topic that encompasses several clinical variables. In order to be ideal, the method should be able to predict patient outcome, should be able to be performed by most care-givers, should be inexpensive, and should not be time-consuming. Unfortunately, most nutritional assessment instruments were published with insufficient details regarding their intended use and method of derivation, and with an inadequate assessment of their effectiveness. Therefore, health professionals should be critical when defining which instrument should be adopted by an institution, and several factors should be taken into consideration.