Medical and neurological complications of ischemic stroke: experience from the RANTTAS trial. RANTTAS Investigators

Functional Outcome After Common Poststroke Complications Occurring in the First 90 Days

Background and Purpose—

The aim of this study was to explore the associations of common medical complications with functional outcome at 90 days post stroke.

Methods—

Patients with unselected acute stroke were included and observed for 16 predefined complications during the first week. Fifty percent (244 patients) were allocated to follow-up of 13 complications until 90 days and then assessed with the modified Rankin Scale 90. Common complications were defined as complications with frequencies of ≥5%. Ordinal logistic regression (worsened outcome), as well as binary logistic regression for severe dependency and death (modified Rankin Scale score>3) was performed.

Results—

Seven of the 13 complications occurred at a frequency ≥5%. Recurrent stroke and chest infection were found to have an odds ratio for worsened outcome of 7.45 (95% confidence interval, 2.83–20.96; P <0.0001) and 3.28 (95% confidence interval, 1.16–9.29; P =0.025), respectively. Infections other than chest infections and urinary tract infections had an odds ratio for worsened outcome of 1.59 (95% confidence interval, 1.12–2.24; P =0.009) and falls an odds ratio of 1.43 (95% confidence interval, 1.06 to 1.93; P =0.021). Myocardial infarction, urinary tract infections, and pain were not associated with a worsened outcome in terms of modified Rankin Scale 90.

Conclusions—

Recurrent stroke and chest infections were strongly associated with a worsened outcome. Other infections and falls were associated with less worsening. For myocardial infarction, urinary tract infections, and pain no association with functional outcome was found. Active strategies for prevention and early treatment of the first 2 complications seem advisable; patient monitoring as part of comprehensive stroke unit care should ensure timely identification and treatment of all complications.

Effect of different antipsychotic drugs on short-term mortality in stroke patients

The safety, tolerability, and efficacy data for antipsychotic drugs used in the acute phase of stroke are limited. The primary aim of this study was to examine the effectiveness and safety of typical and atypical antipsychotics on acute ischemic stroke mortality.This observational study was conducted in a retrospective cohort of patients selected from the 2010-2011 National Health Research Institute database in Taiwan. Patients were tracked for 1 month from the time of their first hospitalization for acute ischemic stroke. A nested case-control analysis was used to estimate the odds ratio (OR) of 30-day mortality associated with antipsychotic drug, adjusted for age, gender, disease severity, and comorbidities.The study cohort included 47,225 subjects with ischemic stroke, including 9445 mortality cases and 37,780 matched controls. After adjustment for the covariates, antipsychotics users before ischemic stroke are associated with a 73% decrease in the rate of mortality (OR 0.27; 95% CI 0.23-0.31). After ischemic stroke, the use of antipsychotics is associated with 87% decrease in the rate of mortality (OR 0.13; 95% CI 0.1-0.16). The users of conventional antipsychotics are associated with a 78% decrease in the rate of mortality (OR 0.22; 95% CI 0.18-0.26). The users of atypical antipsychotics are also associated with a 86% decrease in the rate of mortality (OR 0.14; 95% CI 0.12-0.17).We found that 1-month mortality among acute stroke patients treated with antipsychotics is significantly lower. The benefit on lower mortality was found not only among ischemic stroke patients who had received antipsychotics previously but also among patients who start antipsychotics after their stroke.

Infection after intracerebral hemorrhage: risk factors and association with outcomes in the ethnic/racial variations of intracerebral hemorrhage study

BACKGROUND AND PURPOSE

Risk factors for infections after intracerebral hemorrhage (ICH) and their association with outcomes are unknown. We hypothesized there are predictors of poststroke infection and infections drive worse outcomes.

METHODS

We determined prevalence of infections in a multicenter, triethnic study of ICH. We performed univariate and multivariate analyses to determine the association of infection with admission characteristics and hospital complications. We performed logistic regression on association of infection with outcomes after controlling for known determinants of prognosis after ICH (volume, age, infratentorial location, intraventricular hemorrhage, and Glasgow Coma Scale).

RESULTS

Among 800 patients, infections occurred in 245 (31%). Admission characteristics associated with infection in multivariable models were ICH volume (odds ratio [OR], 1.02/mL; 95% confidence interval [CI], 1.01-1.03), lower Glasgow Coma Scale (OR, 0.91 per point; 95% CI, 0.87-0.95), deep location (reference lobar: OR, 1.90; 95% CI, 1.28-2.88), and black race (reference white: OR, 1.53; 95% CI, 1.01-2.32). In a logistic regression of admission and hospital factors, infections were associated with intubation (OR, 3.1; 95% CI, 2.1-4.5), dysphagia (with percutaneous endoscopic gastrostomy: OR, 3.19; 95% CI, 2.03-5.05 and without percutaneous endoscopic gastrostomy: OR, 2.11; 95% CI, 1.04-4.23), pulmonary edema (OR, 3.71; 95% CI, 1.29-12.33), and deep vein thrombosis (OR, 5.6; 95% CI, 1.86-21.02), but not ICH volume or Glasgow Coma Scale. Infected patients had higher discharge mortality (16% versus 8%; P=0.001) and worse 3-month outcomes (modified Rankin Scale ≥3; 80% versus 51%; P<0.001). Infection was an independent predictor of poor 3-month outcome (OR, 2.6; 95% CI, 1.8-3.9).

CONCLUSIONS

There are identifiable risk factors for infection after ICH, and infections predict poor outcomes.

Acid-suppressive medication use in acute stroke and hospital-acquired pneumonia

OBJECTIVE

Pneumonia is a morbid complication of stroke, but evidence-based strategies for its prevention are lacking. Acid-suppressive medications have been associated with increased risk for nosocomial pneumonia in hospitalized patients. It is unclear whether these results can be extrapolated to stroke patients, where other factors strongly modulate pneumonia risk. We investigated the association between acid-suppressive medication and hospital-acquired pneumonia in patients with acute stroke.

METHODS

All patients hospitalized with acute ischemic stroke or intracerebral hemorrhage in a large, urban academic medical center in Boston, Massachusetts from June 2000 to June 2010 who were ≥18 years of age and hospitalized for ≥2 days were eligible for inclusion. Acid-suppressive medication use was defined as any pharmacy charge for a proton-pump inhibitor or histamine-2 receptor antagonist. Multivariate logistic regression was used to control for confounders. The main outcome measure was hospital-acquired pneumonia, defined via International Classification of Diseases, Ninth Revision, Clinical Modification codes.

RESULTS

The cohort comprised 1,676 admissions. Acid-suppressive medication was ordered in 1,340 (80%) and hospital-acquired pneumonia occurred in 289 (17.2%). The unadjusted incidence of hospital-acquired pneumonia was higher in the group exposed to acid-suppressive medication compared to those unexposed (20.7% vs 3.6%, odds ratio [OR] = 7.0, 95% confidence interval [CI] = 3.9-12.7). After adjustment, the OR of hospital-acquired pneumonia in the exposed group was 2.3 (95% CI = 1.2-4.6). The association was significant for proton-pump inhibitors (OR = 2.7, 95% CI = 1.4-5.4), but not for histamine-2 receptor antagonists (OR = 1.6, 95% CI = 0.8-3.4).

INTERPRETATION

In this large hospital-based cohort of patients presenting with acute stroke, acid-suppressive medication use was associated with increased odds of hospital-acquired pneumonia.

Systemic diseases and oral health

The US population is at the beginning of a significant demographic shift; the American geriatric population is burgeoning, and average longevity is projected to increase in the coming years. Elder adults are affected by numerous chronic conditions, such as diabetes, hypertension, osteoarthritis, osteoporosis, cardiovascular diseases, and cerebrovascular diseases. These older adults need special dental care and an improved understanding of the complex interactions of oral disease and systemic chronic diseases that can complicate their treatment. Oral diseases have strong associations with systemic diseases, and poor oral health can worsen the impact of systemic diseases.

Characteristic adverse events and their incidence among patients participating in acute ischemic stroke trials

BACKGROUND AND PURPOSE

Adverse events (AE) in trial populations present a major burden to researchers and patients, yet most events are unrelated to investigational treatment. We aimed to develop a coherent list of expected AEs, whose incidence can be predicted by patient characteristics that will inform future trials and perhaps general poststroke care.

METHODS

We analyzed raw AE data from patients participating in acute ischemic stroke trials. We identified events that occurred with a lower 99% confidence bound greater than nil. Among these, we applied receiver operating characteristic principles to select the fewest types of events that together represented the greatest number of reports. Using ordinal logistic regression, we modeled the incidence of these events as a function of patient age, sex, baseline National Institutes of Health Stroke Scale, and multimorbidity status, defining P<0.05 as statistically significant.

RESULTS

We analyzed 5775 placebo-treated patients, reporting 21 217 AEs. Among 756 types of AEs, 132 accounted for 82.7%, of which 80% began within 10 days after stroke. Right hemisphere (odds ratio [OR], 1.67), increasing baseline National Institutes of Health Stroke Scale (OR, 1.11), multimorbidity status (OR, 1.09 per disease), patient age (OR, 1.01 per year), height (OR, 1.01 per centimeter), diastolic blood pressure (OR, 0.99 per mm Hg), and smoking (OR, 0.82) were independently associated with developing more AEs but together explained only 13% of the variation.

CONCLUSIONS

A list of 132 expected AEs after acute ischemic stroke may be used to simplify interpretation and reporting of complications. AEs can be modestly predicted by patient characteristics, facilitating stratification of patients by risk for poststroke complications.

Risk score to predict gastrointestinal bleeding after acute ischemic stroke

BACKGROUND

Gastrointestinal bleeding (GIB) is a common and often serious complication after stroke. Although several risk factors for post-stroke GIB have been identified, no reliable or validated scoring system is currently available to predict GIB after acute stroke in routine clinical practice or clinical trials. In the present study, we aimed to develop and validate a risk model (acute ischemic stroke associated gastrointestinal bleeding score, the AIS-GIB score) to predict in-hospital GIB after acute ischemic stroke.

METHODS

The AIS-GIB score was developed from data in the China National Stroke Registry (CNSR). Eligible patients in the CNSR were randomly divided into derivation (60%) and internal validation (40%) cohorts. External validation was performed using data from the prospective Chinese Intracranial Atherosclerosis Study (CICAS). Independent predictors of in-hospital GIB were obtained using multivariable logistic regression in the derivation cohort, and β-coefficients were used to generate point scoring system for the AIS-GIB. The area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration, respectively.

RESULTS

A total of 8,820, 5,882, and 2,938 patients were enrolled in the derivation, internal validation and external validation cohorts. The overall in-hospital GIB after AIS was 2.6%, 2.3%, and 1.5% in the derivation, internal, and external validation cohort, respectively. An 18-point AIS-GIB score was developed from the set of independent predictors of GIB including age, gender, history of hypertension, hepatic cirrhosis, peptic ulcer or previous GIB, pre-stroke dependence, admission National Institutes of Health stroke scale score, Glasgow Coma Scale score and stroke subtype (Oxfordshire). The AIS-GIB score showed good discrimination in the derivation (0.79; 95% CI, 0.764-0.825), internal (0.78; 95% CI, 0.74-0.82) and external (0.76; 95% CI, 0.71-0.82) validation cohorts. The AIS-GIB score was well calibrated in the derivation (P = 0.42), internal (P = 0.45) and external (P = 0.86) validation cohorts.

CONCLUSION

The AIS-GIB score is a valid clinical grading scale to predict in-hospital GIB after AIS. Further studies on the effect of the AIS-GIB score on reducing GIB and improving outcome after AIS are warranted.

Gastrointestinal bleeding in acute ischemic stroke: recent trends from the fukuoka stroke registry

BACKGROUND

Gastrointestinal (GI) hemorrhage is a potentially serious complication of acute stroke, but its incidence appears to be decreasing. The aim of this study was to elucidate the etiology of GI bleeding and its impact on clinical outcomes in patients with acute ischemic stroke in recent years.

METHODS

Using the database of the Fukuoka Stroke Registry, 6,529 patients with acute ischemic stroke registered between June 2007 and December 2012 were included in this study. We recorded clinical data including any previous history of peptic ulcer, prestroke drug history including the use of antiplatelets, anticoagulants, steroids and nonsteroidal anti-inflammatory drugs (NSAIDs), and poststroke treatment with suppressing gastric acidity. GI bleeding was defined as any episode of hematemesis or melena on admission or during hospitalization. The cause and origin of bleeding were diagnosed endoscopically. Logistic regression analysis was used to identify risk factors for GI bleeding and its influence on deteriorating neurologic function, death, and poor outcome.

RESULTS

GI bleeding occurred in 89 patients (1.4%) under the condition that 66% of the total patients received acid-suppressing agents after admission. Multivariate analysis revealed that GI bleeding was associated with the absence of dyslipidemia (p = 0.03), a previous history of peptic ulcer (p < 0.001), and the severity of baseline neurologic deficit (p = 0.002) but not with antiplatelet drugs, anticoagulants, and NSAIDs. The source was the upper GI tract in 51% of the cases; causes included peptic ulceration (28%) and malignancies (12%), and other or unidentified causes accounted for 60%. GI bleeding mostly occurred within 1 week after stroke onset. Hemoglobin concentration fell by a median value of 2.5 g/dl in patients with GI bleeding. Among them, 28 patients underwent blood transfusion (31.5%). After adjustment for confounding factors, GI bleeding was independently associated with neurologic deterioration (OR 3.9, 95% CI 2.3-6.6, p < 0.001), in-hospital death (OR 6.1, 95% CI 3.1-12.1, p < 0.001), and poor outcome at 3 months (OR 6.8, 95% CI 3.7-12.7, p < 0.001). These associations were significant irrespective of whether patients underwent red blood cell transfusion.

CONCLUSIONS

GI bleeding infrequently occurred in patients with acute ischemic stroke, which was mostly due to etiologies other than peptic ulcer. GI bleeding was associated with poor clinical outcomes including neurologic deterioration, in-hospital mortality, and poor functional outcome.

Posttreatment variables improve outcome prediction after intra-arterial therapy for acute ischemic stroke

BACKGROUND

There are multiple clinical and radiographic factors that influence outcomes after endovascular reperfusion therapy (ERT) in acute ischemic stroke (AIS). We sought to derive and validate an outcome prediction score for AIS patients undergoing ERT based on readily available pretreatment and posttreatment factors.

METHODS

The derivation cohort included 511 patients with anterior circulation AIS treated with ERT at 10 centers between September 2009 and July 2011. The prospective validation cohort included 223 patients with anterior circulation AIS treated in the North American Solitaire Acute Stroke registry. Multivariable logistic regression identified predictors of good outcome (modified Rankin score ≤2 at 3 months) in the derivation cohort; model β coefficients were used to assign points and calculate a risk score. Discrimination was tested using C statistics with 95% confidence intervals (CIs) in the derivation and validation cohorts. Calibration was assessed using the Hosmer-Lemeshow test and plots of observed to expected outcomes. We assessed the net reclassification improvement for the derived score compared to the Totaled Health Risks in Vascular Events (THRIVE) score. Subgroup analysis in patients with pretreatment Alberta Stroke Program Early CT Score (ASPECTS) and posttreatment final infarct volume measurements was also performed to identify whether these radiographic predictors improved the model compared to simpler models.

RESULTS

Good outcome was noted in 186 (36.4%) and 100 patients (44.8%) in the derivation and validation cohorts, respectively. Combining readily available pretreatment and posttreatment variables, we created a score (acronym: SNARL) based on the following parameters: symptomatic hemorrhage [2 points: none, hemorrhagic infarction (HI)1-2 or parenchymal hematoma (PH) type 1; 0 points: PH2], baseline National Institutes of Health Stroke Scale score (3 points: 0-10; 1 point: 11-20; 0 points: >20), age (2 points: <60 years; 1 point: 60-79 years; 0 points: >79 years), reperfusion (3 points: Thrombolysis In Cerebral Ischemia score 2b or 3) and location of clot (1 point: M2; 0 points: M1 or internal carotid artery). The SNARL score demonstrated good discrimination in the derivation (C statistic 0.79, 95% CI 0.75-0.83) and validation cohorts (C statistic 0.74, 95% CI 0.68-0.81) and was superior to the THRIVE score (derivation cohort: C statistic 0.65, 95% CI 0.60-0.70; validation cohort: C-statistic 0.59, 95% CI 0.52-0.67; p < 0.01 in both cohorts) but was inferior to a score that included age, ASPECTS, reperfusion status and final infarct volume (C statistic 0.86, 95% CI 0.82-0.91; p = 0.04). Compared with the THRIVE score, the SNARL score resulted in a net reclassification improvement of 34.8%.

CONCLUSIONS

Among AIS patients treated with ERT, pretreatment scores such as the THRIVE score provide only fair prognostic information. Inclusion of posttreatment variables such as reperfusion and symptomatic hemorrhage greatly influences outcome and results in improved outcome prediction.

Rat middle cerebral artery occlusion is not a suitable model for the study of stroke-induced spontaneous infections

Background

Infections related to stroke-induced immunodepression are an important complication causing a high rate of death in patients. Several experimental studies in mouse stroke models have described this process but it has never been tested in other species such as rats.

Methods

Our study focused on the appearance of secondary systemic and pulmonary infections in ischemic rats, comparing with sham and naive animals. For that purpose, male Wistar rats were subjected to embolic middle cerebral artery occlusion (eMCAO) or to transient MCAO (tMCAO) inserting a nylon filament. Forty-eight hours after ischemia, blood and lung samples were evaluated.

Results

In eMCAO set, ischemic rats showed a significant decrease in blood-peripheral lymphocytes (naive = 58.8±18.1%, ischemic = 22.9±16.4%) together with an increase in polymorphonuclears (PMNs) (naive = 29.2±14.7%, ischemic = 71.7±19.5%), while no change in monocytes was observed. The increase in PMNs counts was positively correlated with worse neurological outcome 48 hours after eMCAO (r = 0.55, p = 0.043). However, sham animals showed similar changes in peripheral leukocytes as those seen in ischemic rats (lymphocytes: 40.1±19.7%; PMNs: 51.7±19.2%). Analysis of bacteriological lung growth showed clear differences between naive (0±0 CFU/mL; log10) and both sham (3.9±2.5 CFU/mL; log10) and ischemic (4.3±2.9 CFU/mL; log10) groups. Additionally, naive animals presented non-pathological lung histology, while both sham and ischemic showed congestion, edema or hemorrhage. Concordant results were found in the second set of animals submitted to a tMCAO.

Conclusions

Inflammatory and infection changes in Wistar rats subjected to MCAO models may be attributed not only to the brain ischemic injury but to the surgical aggression and/or anaesthetic stress. Consequently, we suggest that stroke-induced immunodepression in ischemic experimental models should be interpreted with caution in further experimental and translational studies, at least in rat stroke models that entail cervicotomy and cranial trepanation.

Risk assessment of deep-vein thrombosis after acute stroke: a prospective study using clinical factors

AIMS

Deep-vein thrombosis (DVT) represents a serious complication in acute stroke patients with pulmonary embolus (PE) as a potential outcome. Prediction of DVT may help with formulating a proper prevention strategy. To assess of the risk of deep venous thrombosis (DVT) in acute stroke patients, we developed and validated a clinical score in a cohort study.

METHODS

Incidence of Deep Venous Thrombosis after Acute Stroke in China (INVENT-China) is a multicenter prospective cohort study. The potential predictive variables for DVT at baseline were collected, and the presence of DVT was evaluated using ultrasonography on the 14 ± 3 days. Data were randomly assigned to either a training data set or a test data set. Multivariate logistic regression analysis was used to develop risk scores to predict DVT in the training data set and the area under the receiver operating characteristic curve to validate the score in the test data set.

RESULTS

From 2006-2007, 862 hospital-based acute stroke patients were enrolled in China. The overall incidence of DVT after acute stroke within two weeks was 12.4% (95%CI 10.3-14.7%). A seven-point score derived in the training data set (age [≥65 years = 1], sex [female gender = 1]), obesity [BMI ≥ 25 kg/m(2) = 1], active cancer [yes = 2], stroke subtype [cerebral hemorraghe = 1], muscle weakness [≥2 on Lower limb NIHSS score = 1] was highly predictive of 14-day risk of DVT(c statistic = 0.70, 95% CI, 0.64-0.76, P < 0.001), in the overall study population(c statistic = 0.65, 95% CI 0.59-0.70, P < 0.001).

CONCLUSIONS

This clinical score may help identify acute stroke patients with high risk of DVT. In addition, it also serves as a platform to develop further models of DVT prediction in stroke patients based on clinical factors.

Age-based prediction of incidence of complications during inpatient stroke rehabilitation: a retrospective longitudinal cohort study

Background

Stroke complications can occur not only in the acute ward but also during the subsequent rehabilitation period. However, existing studies have not adequately addressed the incidence of various complications among stroke in patients undergoing rehabilitation using a longitudinal method. We aimed to investigate the longitudinal impact of age on complication rates in patients undergoing inpatient stroke rehabilitation at different disease stages.

Methods

Five hundred and sixty-eight first-time stroke patients transferred to the rehabilitation ward between July 2002 and June 2012 were included in the study. Patients were stratified into age groups for comparison: <65 years (young), 65 years to <75 years (younger old), and ≥75 years (older old). In total, 30 different complication types were recorded for analysis.

Results

Constipation, shoulder pain, symptomatic urinary tract infection (UTI), and fever were common complications during initial stay in the rehabilitation ward, and incidence was >10% in all three age groups. The frequency of incidence of upper gastrointestinal bleeding (UGIB) was higher in the younger old (17.9%) and older old (20.6%) groups than in the young group (4.1%) during initial stay in the rehabilitation ward (p < 0.001). The incidence of UGIB was higher in the younger old (8.04%) and older old (8.33%) groups than in the young group (0.19%) during subsequent stay in the rehabilitation ward (p = 0.011). The incidence of symptomatic UTI was higher in the younger old (21.0%) and older old (20.0%) groups than in the young group (11.5%) during initial stay in the rehabilitation ward (p = 0.019). The incidence of symptomatic UTI was higher in the older old group (29.17%) than in the younger old (9.21%) and young (3.14%) groups during subsequent stay in the rehabilitation ward (p < 0.001).

Conclusions

Age does not affect every complication type. UGIB and symptomatic UTI occurred more frequently in stroke patients aged ≥65 years during their stay in the rehabilitation ward.

C-reactive protein as a prognostic marker after lacunar stroke: levels of inflammatory markers in the treatment of stroke study

BACKGROUND AND PURPOSE

Inflammatory biomarkers predict incident and recurrent cardiac events, but their relationship to stroke prognosis is uncertain. We hypothesized that high-sensitivity C-reactive protein (hsCRP) predicts recurrent ischemic stroke after recent lacunar stroke.

METHODS

Levels of Inflammatory Markers in the Treatment of Stroke (LIMITS) was an international, multicenter, prospective ancillary biomarker study nested within Secondary Prevention of Small Subcortical Strokes (SPS3), a phase III trial in patients with recent lacunar stroke. Patients were assigned in factorial design to aspirin versus aspirin plus clopidogrel, and higher versus lower blood pressure targets. Patients had blood samples collected at enrollment and hsCRP measured using nephelometry at a central laboratory. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for recurrence risks before and after adjusting for demographics, comorbidities, and statin use.

RESULTS

Among 1244 patients with lacunar stroke (mean age, 63.3±10.8 years), median hsCRP was 2.16 mg/L. There were 83 recurrent ischemic strokes (including 45 lacunes) and 115 major vascular events (stroke, myocardial infarction, and vascular death). Compared with the bottom quartile, those in the top quartile (hsCRP>4.86 mg/L) were at increased risk of recurrent ischemic stroke (unadjusted HR, 2.54; 95% CI, 1.30-4.96), even after adjusting for demographics and risk factors (adjusted HR, 2.32; 95% CI, 1.15-4.68). hsCRP predicted increased risk of major vascular events (top quartile adjusted HR, 2.04; 95% CI, 1.14-3.67). There was no interaction with randomized antiplatelet treatment.

CONCLUSIONS

Among recent lacunar stroke patients, hsCRP levels predict the risk of recurrent strokes and other vascular events. hsCRP did not predict the response to dual antiplatelets.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00059306.

Immunological consequences of ischemic stroke

The treatment of ischemic stroke is one of the great challenges in modern neurology. The localization and the size of the infarct determine the long-term disability of stroke survivors. Recent observations have revealed that stroke also alters the function of the immune system and vice versa: At the site of the infarct, a local inflammatory response develops that enhances brain lesion development. In experimental stroke, proof-of-concept studies confirm that inhibition of this immune response reduces lesion volume and improves outcome. In the peripheral blood of stroke patients, though, lymphocytopenia and monocyte dysfunction develop. These changes reflect a clinically relevant impairment of bacterial defense mechanisms because they are associated with an enhanced risk to acquire post-stroke infections. Stress hormones have been identified as important mediators of stroke-induced immune suppression. The pharmacological inhibition of beta adrenergic receptors, but not the inhibition of steroids, is effective in reducing infection and improving clinical outcome in experimental stroke; catecholamine release therefore appears causally related to stroke-induced immune suppression. Strong evidence supports the hypothesis that these immune alterations impact the clinical course of stroke patients. Thus, the development of new therapeutic strategies targeted to alter the immunological consequences of stroke appears promising. However, to date, the beneficial effects seen in experimental stroke have not been successfully translated into a clinical trial. This brief review summarizes the current understanding of the immunological consequences of ischemic stroke. Finally, we propose a concept that links the peripheral immune suppression with the development of local inflammation.

Pulmonary embolism in ischemic stroke: clinical presentation, risk factors, and outcome

Background

Limited information is available on the frequency of pulmonary embolism (PE) in patients with an acute ischemic stroke (AIS). We evaluated clinical characteristics, predisposing factors, and outcomes in AIS patients with PE.

Methods and Results

We included all AIS patients admitted to participating institutions in the Registry of the Canadian Stroke Network. Clinically PE was documented by a physician and confirmed by computed tomography pulmonary angiography within 30 days of the stroke case index. The primary outcome was death or disability at discharge. Secondary outcomes included disposition, length of hospital stay, mortality at 3 months and 1 year. Among 11 287 patients with AIS, PE was found in 89 (0.78%) patients. History of cancer, deep vein thrombosis (DVT)/PE, and DVT during the hospitalization were associated with PE. PE was associated with higher risk of death at 30 days (25.8% versus 13.6%; P<0.001), at 1 year (47.2% versus 24.6%; P<0.001), and disability at discharge (85.4% versus 63.6%; P<0.001). Mean length of stay was longer in stroke patients with PE (36 versus 16 days; P=0.001). After adjusting for age, sex, and stroke severity, PE remained associated with lower survival at 30 days and 1 year, and death or disability at discharge (OR 3.02; 95% CI 1.56 to 5.83).

Conclusions

In this large cohort study, PE occurred in nearly 1% of AIS patients. PE was more common in patients with severe stroke, history of cancer, previous DVT/PE or acute DVT and associated with lower short‐ and long‐term survival, greater disability, and longer length of stay.

Gastrointestinal bleeding after intracerebral hemorrhage: a retrospective review of 808 cases

BACKGROUND

This study examined the incidence and risk factors for gastrointestinal (GI) bleeding after spontaneous intracerebral hemorrhage (ICH).

METHODS

The available medical records of patients with ICH admitted from June 2008 to December 2009 for any episode of GI bleeding, possible precipitating factors and administration of ulcer prophylaxis were reviewed.

RESULTS

The prevalence of GI bleeding was 26.7%, including 3 cases of severe GI bleeding (0.35%). Patients with GI bleeding had significantly longer hospital stay and higher in-hospital mortality compared with patients without GI bleeding. Multivariate logistic regression analyses showed that age, Glasgow Coma Scale scores, sepsis and ICH volume were independent predictors of GI bleeding. About 63.4% of patients with ICH received stress ulcer prophylaxis.

CONCLUSIONS

GI bleeding occurred frequently after ICH, but severe events were rare. Age, Glasgow Coma Scale score, sepsis and ICH volume were independent predictors of GI bleeding occurring after ICH.

Interrelationship among common medical complications after acute stroke: pneumonia plays an important role

BACKGROUND AND PURPOSE

Medical complications are common among patients with stroke. However, little is known about the potential interrelationship among them. In the present study, we aimed to investigate the association between common in-hospital medical complications after acute ischemic stroke (AIS) and spontaneous intracerebral hemorrhage (ICH).

METHODS

We analyzed patients enrolled in the China National Stroke Registry from 2007 to 2008. The occurrence of 11 common stroke-associated medical complications during acute hospitalization was prospectively registered. Multivariable analysis using generalized estimation equation was performed to assess association between medical complications in AIS and ICH cohort, respectively.

RESULTS

A total of 14 702 patients with AIS and 5221 patients with ICH were enrolled. The median age was 65 years (interquartile range, 55-74 years), and 38.1% were female. The median length of hospital stay was 14 days (interquartile range, 10-20 days) for AIS and 18 days (interquartile range, 11-26 days) for ICH. Pneumonia was the most common medical complication after AIS (11.4%) and ICH (16.8%). In the AIS cohort, after adjusting for potential confounders, pneumonia was significantly associated with development of gastrointestinal bleeding (adjusted odds ratio [OR], 8.35; 95% confidence interval [CI], 6.27-11.1; P<0.001), decubitus ulcer (adjusted OR, 5.31; 95% CI, 3.39-8.31; P<0.001), deep vein thrombosis (adjusted OR, 4.27; 95% CI, 2.41-7.59; P<0.001), epileptic seizure (adjusted OR, 3.96; 95% CI, 2.67-5.88; P<0.001), urinary tract infection (adjusted OR, 3.34; 95% CI, 2.73-4.10; P<0.001), atrial fibrillation/flutter (adjusted OR, 3.17; 95% CI, 2.58-3.90; P<0.001), and recurrent stroke (adjusted OR, 2.65; 95% CI, 2.07-3.40; P<0.001). Similar significant association between pneumonia and development of several nonpneumonia medical complications was verified in ICH cohort as well.

CONCLUSIONS

Pneumonia is closely associated with the development of several nonpneumonia medical complications after AIS and ICH.

Influence of acute complications on outcome 3 months after ischemic stroke

BACKGROUND

Early medical complications are potentially modifiable factors influencing in-hospital outcome. We investigated the influence of acute complications on mortality and poor outcome 3 months after ischemic stroke.

METHODS

Data were obtained from patients admitted to one of 13 stroke units of the Berlin Stroke Registry (BSR) who participated in a 3-months-follow up between June 2010 and September 2012. We examined the influence of the cumulative number of early in-hospital complications on mortality and poor outcome (death, disability or institutionalization) 3 months after stroke using multivariable logistic regression analyses and calculated attributable fractions to determine the impact of early complications on mortality and poor outcome.

RESULTS

A total of 2349 ischemic stroke patients alive at discharge from acute care were included in the analysis. Older age, stroke severity, pre-stroke dependency and early complications were independent predictors of mortality 3 months after stroke. Poor outcome was independently associated with older age, stroke severity, pre-stroke dependency, previous stroke and early complications. More than 60% of deaths and poor outcomes were attributed to age, pre-stroke dependency and stroke severity and in-hospital complications contributed to 12.3% of deaths and 9.1% of poor outcomes 3 months after stroke.

CONCLUSION

The majority of deaths and poor outcomes after stroke were attributed to non-modifiable factors. However, early in-hospital complications significantly affect outcome in patients who survived the acute phase after stroke, underlining the need to improve prevention and treatment of complications in hospital.

In-Hospital Cardiac Complications after Intracerebral Hemorrhage

Background and purpose

Data on cardiac complications and their precipitants after intracerebral hemorrhage are scarce. We examined the frequency and risk factors for serious in-hospital cardiac events in a large cohort of consecutive intracerebral hemorrhage patients.

Methods

A retrospective chart review of 1013 consecutive patients with nontraumatic intracerebral hemorrhage treated at the Helsinki University Central Hospital (2005–2010). We excluded patients with intraparenchymal hematoma related to sub-arachnoid hemorrhage or intracerebral hemorrhage because of fibrinolytic therapies for acute ischemic stroke or myocardial infarction. Serious in-hospital cardiac event was defined as any of in-hospital poststroke acute myocardial infarction, ventricular fibrillation or tachycardia, moderate to serious acute heart failure, or cardiac death.

Results

Among the 948 patients included, ≥1 serious in-hospital cardiac event occurred in 39 (4·1%) patients after a median delay of two-days from stroke onset (acute myocardial infarction in three patients, ventricular fibrillation or tachycardia in three patients, acute heart failure in 36 patients, and cardiac death in three patients). Hospital stay was longer in patients with serious in-hospital cardiac event than in those without (median 12, interquartile range 7–19 vs. 8, 3–14; P = 0·001), with no difference in in-hospital mortality (23·1% vs. 24·3%; P = 0·86). In multivariable logistic regression analysis adjusted for age, gender, and diabetes, atrial fibrillation during hospitalization (odds ratio 6·68 for new-onset atrial fibrillation, 95% confidence interval 2·11–21·18; 4·46 for old atrial fibrillation, 2·08–9·56), and history of myocardial infarction (3·20, 1·18–8·66) were independently associated with serious in-hospital cardiac events.

Conclusions

After intracerebral hemorrhage, 4% of patients suffer an acute serious cardiac complication. Those with history of myocardial infarction or in-hospital atrial fibrillation are at greater risk for such events.

Serious adverse events experienced by survivors of stroke in the first year following discharge from inpatient rehabilitation

PURPOSE

To identify the incidence of adverse events (AE) that occurred in stroke survivors during the first year following discharge from inpatient rehabilitation and to determine the type and patterns of AE.

METHODS

Data were collected for 12 months on events resulting in admissions to the emergency department, hospital, long-term care facility, or death. Descriptive statistics were used to depict the patterns of AE and univariate comparisons were made of the differences between survivors who did or did not experience one or more AE.

RESULTS

Of the 159 participants, 50% reported a total of 163 AE. Most AE (82.2%) were unexpected and the majority occurred during the first 6 months; 12 recurrent strokes and 6 transient ischemic attacks occcurred.

CONCLUSIONS

Education on prevention and treatment of common AE is important prior to discharge. Anticipatory guidance may help survivors and caregivers modify their lifestyle and prevent common AE.

Hospital acquired pneumonia is linked to right hemispheric peri-insular stroke

PURPOSE

Hospital acquired pneumonia (HAP) is a major complication of stroke. We sought to determine associations between infarction of specific brain regions and HAP.

METHODS

215 consecutive acute stroke patients with HAP (2003-2009) were carefully matched with 215 non-pneumonia controls by gender, then NIHSS, then age. Admission imaging and binary masks of infarction were registered to MNI-152 space. Regional atlas and voxel-based log-odds were calculated to assess the relationship between infarct location and the likelihood of HAP. An independently validated penalized conditional logistic regression model was used to identify HAP associated imaging regions.

RESULTS

The HAP and control patients were well matched by gender (100%), age (95% within 5-years), NIHSS (98% within 1-point), infarct size, dysphagia, and six other clinical variables. Right hemispheric infarcts were more frequent in patients with HAP versus controls (43.3% vs. 34.0%, p = 0.054), whereas left hemispheric infarcts were more frequent in controls (56.7% vs. 44.7%, p = 0.012); there was no significant difference between groups in the rate of brainstem strokes (p = 1.0). Of the 10 most infarcted regions, only right insular cortex volume was different in HAP versus controls (20 vs. 12 ml, p = 0.02). In univariate analyses, the highest log-odds regions for pneumonia were right hemisphere, cerebellum, and brainstem. The best performing multivariate model selected 7 brain regions of infarction and 2 infarct volume-based variables independently associated with HAP.

CONCLUSIONS

HAP is associated with right hemispheric peri-insular stroke. These associations may be related to autonomic modulation of immune mechanisms, supporting recent hypotheses of stroke mediated immune suppression.

The ischaemic ECG: is it all in the head?

Acute cerebrovascular events including ischaemic stroke and subarachnoid haemorrhage are known to be associated with left ventricular dysfunction and significant electrocardiographic abnormalities that can mimic cardiac ischaemia. The authors present a case in which an intracerebral haemorrhage was diagnosed during the treatment of pneumonia in a 62-year-old woman, with repolarisation abnormalities on the ECG acting as the key diagnostic clue in the absence of clinical or radiological evidence of ventricular dysfunction. The pneumonia was treated without complication, and there were no long-term respiratory, cardiac or neurological sequelae. Diagnostic cardiac imaging, including angiography at follow-up, confirmed the absence of significant coronary artery disease, suggesting a non-coronary aetiology for these ECG changes. The authors emphasise that when presentation is atypical for acute coronary syndrome, non-specific ECG changes could point to a primary cerebrovascular pathology, even in the absence of neurological or cardiac symptoms.

Troponin T in acute ischemic stroke

Multiple interactions are considered to occur among the various forms of cardiovascular and cerebrovascular diseases. The aim of this study was to assess the serum level profile of cardiac troponin T (cTnT) in patients with acute ischemic stroke (AIS) to evaluate factors associated with increased serum levels of cTnT. Patients with AIS enrolled in this prospective observational study were admitted to the hospital <12 hours after stroke onset. At admission, and 4 hours later, all patients were subjected to neurologic examinations and brain computed tomography or magnetic resonance imaging; standard laboratory tests, including cTnT and other cardiac markers; and repeated electrocardiography. Correlations between cTnT and several baseline parameters were tested, and multivariate regression analysis was used to assess the predictors of cTnT elevation. In total, 107 consecutive patients with AIS (65 men, mean age 67.2 ± 14.2 years) were enrolled. Thirty-nine patients (36.4%) presented with elevated cTnT above the upper limit of normal. The cTnT levels were correlated significantly with age (r = 0.448) and the levels of N-terminal pro-brain natriuretic peptide (r = 0.528), cystatin C (r = 0.457), creatine kinase-MB mass (r = 0.253), urea (r = 0.281), and albumin (r = -0.219). Multiple logistic regression analysis found creatinine >90 μmol/L (odds ratio 3.45, 95% confidence interval 1.09 to 10.85), N-terminal pro-brain natriuretic peptide (odds ratio 100 μg/L increase 1.09, 95% confidence interval 1.03 to 1.16), and creatine kinase-MB mass (odds ratio per 1 μg/L increase 1.45, 95% confidence interval 1.04 to 2.04) were associated with cTnT elevation in patients with AIS. In conclusion, elevated cTnT can be frequently detected in patients with AIS. To reliably identify patients with current acute myocardial impairment, more in-depth clinical investigation is needed.

Superiority of preventive antibiotic treatment compared with standard treatment of poststroke pneumonia in experimental stroke: a bed to bench approach

Stroke patients are prone to life-threatening bacterial pneumonia. Previous experimental stroke studies have demonstrated that preventive antibiotic treatment (PAT) improves outcome compared with placebo treatment, which however does not model the clinical setting properly. Here we investigate whether PAT is superior to the current clinical 'gold standard' for treating poststroke infections. Therefore, we modeled stroke care according to the current stroke guidelines recommending early antibiotic treatment after diagnosing infections. To reliably diagnose pneumonia in living mice, we established a general health score and a magnetic resonance imaging protocol for radiologic confirmation. Compared with standard treatment after diagnosis by these methods, PAT not only abolished pneumonia successfully but also improved general medical outcome. Both, preventive and standard antibiotic treatment using enrofloxacin improved survival in a similar way compared with placebo treatment. However, in contrast to standard treatment, only PAT improved functional outcome assessed by gait analysis. In conclusion, standard and preventive treatment approach reduced poststroke mortality, however at the cost of a worse neurologic outcome compared with preventive approach. These data support the concept of PAT for treating patients at risk for poststroke infections and warrant phase III trials to prove this concept in clinical setting.

Stroke-associated pneumonia: major advances and obstacles

BACKGROUND

Stroke-associated pneumonia (SAP) has been implicated in the morbidity, mortality and increased medical cost after acute ischemic stroke. The annual cost of SAP during hospitalization in the United States approaches USD 459 million. The incidence and prognosis of SAP among intensive care unit (ICU) patients have not been thoroughly investigated. We reviewed the pathophysiology, microbiology, incidence, risk factors, outcomes and prophylaxis of SAP with special attention to ICU studies.

METHODS

To determine the incidence, risk factors and prognosis of acute SAP, PubMed was searched using the terms 'pneumonia' AND 'neurology intensive unit' and the MeSH terms 'stroke' AND 'pneumonia'. Non-English literature, case reports and chronic SAP studies were excluded. Studies were classified into 5 categories according to the setting they were performed in: neurological intensive care units (NICUs), medical intensive care units (MICUs), stroke units, mixed studies combining more than one setting or when the settings were not specified and rehabilitation studies.

RESULTS

The incidences of SAP in the following settings were: NICUs 4.1-56.6%, MICUs 17-50%, stroke units 3.9-44%, mixed studies 3.9-23.8% and rehabilitation 3.2-11%. The majority of NICU and MICU studies were heterogeneous including different neurovascular diseases, which partly explains the wide range of SAP incidence. The higher incidence in the majority of ICU studies compared to stroke units or acute floor studies is likely explained by the presence of mechanical ventilation, higher stroke severity causing higher rates of aspiration and stroke-induced immunodepression among ICU patients. The short-term mortality of SAP was increased among the mixed and stroke unit studies ranging between 10.1 and 37.3%. SAP was associated with worse functional outcome in the majority of stroke unit and floor studies. Mortality was less consistent among NICU and MICU studies. This difference could be due to the heterogeneity of ICU studies and the effect of small sample size or other independent risk factors for mortality such as the larger neurological deficit, mechanical ventilation, and age, which may simultaneously increase the risk of SAP and mortality confounding the outcomes of SAP itself. The pathophysiology of SAP is likely explained by aspiration combined with stroke-induced immunodepression through complex humeral and neural pathways that include the hypothalamic-pituitary-adrenal axis, parasympathetic and sympathetic systems.

CONCLUSIONS

A unified definition of SAP, strict inclusion criteria, and the presence of a long-term follow-up need to be applied to the future prospective studies to better identify the incidence and prognosis of SAP, especially among ICU patients.

Greater stroke severity predominates over all other factors for the worse outcome of cardioembolic stroke

BACKGROUND

Cardioembolic (CE) strokes are more disabling and more fatal than non-CE strokes. Multiple prognostic factors have been recognized, but the magnitude of their relative contributions has not been well explored.

METHODS

Using a prospective stroke outcome database, we compared the 3-month outcomes of CE and non-CE strokes. We assessed the relative contribution of each prognostic factor of initial stroke severity, poststroke complications, and baseline characteristics with multivariable analyses and model fitness improvement using -2 log-likelihood and Nagelkerke R2.

RESULTS

This study included 1233 patients with acute ischemic stroke: 193 CE strokes and 1040 non-CE strokes. Compared with the non-CE group, CE group had less modified Rankin Scale (mRS) 0-2 outcomes (47.2% versus 68.5%; odds ratio [95% confidence interval], .41 [.30-.56]), less mRS 0-1 outcomes (33.7% versus 53.5%; .44 [.32-.61]), more mRS 5-6 outcomes (32.1% versus 10.9%; 3.88 [2.71-5.56]), and higher mortality (19.2% versus 5.2%; 4.33 [2.76-6.80]) at 3 months. When adjusting either baseline characteristics or poststroke complications, the outcome differences between the 2 groups remained significant. However, adjusting initial National Institute of Health Stroke Scale (NIHSS) score alone abolished all outcome differences except for mortality. For mRS 0-2 outcomes, the decrement of -2 log-likelihood and the Nagelkerke R2 of the model adjusting initial NIHSS score alone approached 70.2% and 76.7% of the fully adjusting model.

CONCLUSION

Greater stroke severity predominates over all other factors for the worse outcome of CE stroke. Primary prevention and more efficient acute therapy for stroke victims should be given top priorities to reduce the burden of CE strokes.

Correlation between inflammatory factors and post-stroke pneumonia in diabetic patients

Pneumonia is the most common cause of mortality in stroke patients and it has been demonstrated to contribute to mortality and poor functional outcome following stroke in the majority of clinical studies. The risk of infection may be attributed to stroke-induced immunodepression syndrome (SIDS). Cytokine production is increased in SIDS. However, the correlation between biomarkers and the risk of post-stroke pneumonia in patients with diabetes mellitus is not clear. The aim of this study was to determine the correlation between pneumonia and the levels of C-reactive protein (CRP) and interleukin-6 (IL-6), as well as to identify early predictors of pneumonia in acute ischemic stroke patients with diabetes mellitus. Additionally, we investigated the impact of pneumonia on functional outcome after 1 month. A total of 106 ischemic stroke patients with diabetes mellitus who were admitted after the onset of symptoms were included in the study. They were divided into two groups, the pneumonia and non-pneumonia groups. CRP, IL-6, white blood cells (WBCs), mean body temperature and National Institutes of Health Stroke Scale (NIHSS) score were measured at the time of admission. The modified Rankin Scale score was assessed at 30 days. The levels of IL-6, CRP and WBCs, as well as mean body temperature were significantly higher in the patients with pneumonia than in the patients without pneumonia. There were also significant differences between the pneumonia and non-pneumonia groups in age, admission NIHSS score, length of hospital stay and dysphagia. Pneumonia patients had worse outcomes compared with patients without pneumonia at 1 month. Age, NIHSS score and dysphagia were significantly associated with pneumonia. WBCs and mean body temperature were not significant predictors of pneumonia. Older patients with more severe ischemic stroke are more susceptible to the development of pneumonia during the stay in hospital. Pneumonia contributes to poor functional outcome. IL-6, CRP, age, NIHSS score and dysphagia may predict the occurrence of pneumonia on the day of stroke symptom onset.

Long-term morbidities in stroke survivors: a prospective multicenter study of Thai stroke rehabilitation registry

BACKGROUND

Stroke-related complications are barriers to patients' recovery leading to increasing morbidity, mortality, and health care costs, decreasing patient's quality of life. The purpose of this study was to quantify incidence and risk factors of stroke-related complications during the first year after discharge from rehabilitation ward.

METHODS

A prospective observational study was conducted in nine tertiary-care rehabilitation centers. We evaluated the incidence of morbidities during the first year after stroke, including musculoskeletal pain, neuropathic pain, pneumonia, deep vein thrombosis (DVT), pressure ulcer, spasticity, shoulder subluxation, joint contracture, dysphagia, urinary incontinence, anxiety and depression. The complications at discharge and at month-12 were compared using the McNemar test. Univariate analysis and multiple logistic regression analysis by forward stepwise method were used to determine factors predicting the complications at month-12.

RESULTS

Two hundred and fourteen from 327 patients (65.4%) were included. The age was 62.1 ± 12.5 years, and 57.9% were male. In 76.8% of the patients at least one complication was found during the first year after stroke. Those complications were musculoskeletal pain (50.7%), shoulder subluxation (29.3%), depression (21.2%), spasticity (18.3%), joint contracture (15.7%) and urinary incontinence (14.4%). Other complications less than 5% were dysphagia (3.5%), pressure ulcer (2.6%), infection (1.5%), and neuropathic pain (3.0%). Nearly 60% of patients with complications at discharge still had the same complaints after one year. Only 7.6% were without any complication. Morbidity was significantly associated with age and type of stroke. Using multiple logistic regression analysis, age and physical complications at discharge were significant risk factors for physical and psychological morbidities after stroke respectively (OR = 2.1, 95% CI 1.2, 3.7; OR = 3.1, 95% CI 1.3, 7.1).

CONCLUSION

Long-term complications are common in stroke survivors. More than three-fourths of the patients developed at least one during the first year after rehabilitation. Strategies to prevent complications should be concerned especially on musculoskeletal pain which was the most common complaint. Physical complications at discharge period associated with psychological complications at 1 year followed up. More attention should be emphasized on patients age older than 60 years who were the major risk group for developing such complications.

Spontaneous coronary thrombosis following thrombolytic therapy for acute cardiovascular accident and stroke: a case study

Cardiac complications following stroke or acute cerebrovascular accidents (CVA) are common; however, many of these complications are asymptomatic and do not cause adverse cardiac effects. Symptomatic events (such as acute myocardial infarction after CVA) rarely occur and are often the result of an underlying cardiac embolic source, such as a left ventricular thrombus. We report a case of spontaneous coronary thrombosis following thrombolytic therapy for acute CVA, and discuss the implication that an underlying systemic pro-thrombotic state may predispose individuals to thrombosis in disparate vascular beds.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates.

METHODS

Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm.

RESULTS

The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.

CONCLUSIONS

Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

Early blood-based microbiological testing is ineffective in severe stroke patients

BACKGROUND AND PURPOSE

Patients with severe acute stroke are at high risk for systemic infections which are associated with an increase in morbidity and mortality; nevertheless current guidelines do not recommend prophylactic antibiotic therapy. Sensitive detection of pathogens in the blood is desirable to guide early antibiotic therapy. We studied the yield of blood culture testing and microbiological PCR-based methods for early detection of post-stroke bacteremia.

METHODS

Serial blood culture tests either during the first fever episode (>38.5°C) or 24h after admission were performed every 12h for up to 96h after admission. Additionally, microbiological PCR-based techniques for the detection of microbiological pathogens were performed once during the first fever episode prior to initiating antibiotic treatment.

RESULTS

21 severely affected acute stroke patients deemed at high risk for systemic infections (median (interquartile range (IQR)) at admission NIHSSS 19 (15-30) were enrolled; 20 patients were intubated within 5h after ICU admission. All patients developed clinical signs and laboratory constellations compatible with systemic infections within 36h after admission. However, no patient had pathogenic bacteria either in serial blood culture analyses during the first 96h after admission or by PCR-based techniques.

CONCLUSIONS

Very early bacteremia seems not to be a feature of severe stroke in patients despite signs of early immune system depression and frequent subsequent evidence of infection including pneumonia. Consequently our data suggests, that routine early blood-based standard or molecular microbiological assays do not reveal bacteremia, this finding questions the usefulness of their routine performance in this context.

Trends in smoking cessation counseling: experience from American Heart Association-get with the guidelines

BACKGROUND

Successful smoking cessation in stroke and coronary artery disease (CAD) patients is important, as smoking contributes to significant morbidity and mortality. The American Heart Association developed Get With The Guidelines (GWTG) to improve compliance with national guideline recommendations for cardiovascular care. Using data from GWTG, we examined trends associated with the smoking-cessation counseling (SCC) performance measure.

HYPOTHESIS

Implementation of a systematic quality improvement program will increase compliance with the SCC performance measure.

METHODS

We evaluated compliance with SCC in current or recent smokers identified from 224 671 CAD admissions between 2002 and 2008 in the GWTG-CAD database, and from 405 681 stroke admissions between 2002 and 2007 in the GWTG-Stroke database. Additionally, we examined adherence to other performance and quality measures related to CAD and stroke care.

RESULTS

Overall, 55 904 GWTG-CAD and 58 865 GWTG-Stroke admissions were used for the analysis. Rates of SCC improved in each successive year during the study, from 67.6% to 97.4% (P < 0.001) in GWTG-CAD and from 40.1% to 90.7% (P < 0.001) in GWTG-Stroke. Compliance with SCC was up to 34.7% lower (P < 0.0001) in GWTG-Stroke compared with GWTG-CAD, but this difference decreased to 6.7% (P < 0.0001) by the end of the study period. Compliance with many other performance and quality measures was significantly lower among patients not receiving SCC.

CONCLUSIONS

Get With The Guidelines has improved compliance with the SCC performance measure among patients with CAD and stroke. Although the initial disparity in rates of SCC between CAD and stroke patients gradually improved, the difference remained significant.

The systemic response to brain injury and disease

The idea that the brain is immunologically privileged and displays an atypical leukocyte recruitment profile following injury has influenced our ideas about how signals might be carried between brain and the periphery. For many, this has encouraged a cerebrocentric view of immunological responses to CNS injury, with little reference to the potential contribution from other organs. However, it is clear that bidirectional pathways between the brain and the peripheral immune system are important in the pathogenesis of CNS disease. In recent years, we have begun to understand the signals that are carried to the periphery and discovered new functions for known chemokines, made by the liver in response to brain injury, as important regulators of the CNS inflammatory response.

Autoimmune responses to brain following stroke

This review provides a synthesis of the work done by our laboratory that demonstrates the presence of cellular immune responses directed towards brain antigens in animals following experimental stroke as well as in patients following ischemic stroke. These responses include both antigen-specific TH1(+) responses, which are associated with worse stroke outcome, and antigen-specific TREG responses, which are associated with better stroke outcome. The likelihood of developing a detrimental TH1(+) response to brain antigens is increased by administration of a systemic inflammatory stimulus in experimental stroke and by systemic infection in patients with stroke. We propose that the microenvironment within the lymph nodes and brain is altered by systemic inflammation and allows for bystander activation of lymphocytes and the development of autoimmune responses to brain antigens following cerebral ischemic injury.

Cardiovascular and neurological causes of sudden death after ischaemic stroke

Sudden death is an important but widely under-recognised consequence of stroke. Acute stroke can disturb central autonomic control, resulting in myocardial injury, electrocardiographic abnormalities, cardiac arrhythmias, and ultimately sudden death. Experimental and clinical evidence suggests that autonomic imbalance is more frequent after infarcts involving the insular cortex, a crucial region for the control of sympathetic and parasympathetic autonomic functions. Cardiovascular comorbidities increase the risk of cardiac morbidity and mortality after stroke. Thus, many sudden deaths and serious non-fatal cardiac events after stroke are probably due to an interaction between cardiovascular and neurological causes. The exact mechanisms leading to sudden death remain incompletely understood. Further research is needed to investigate the autonomic consequences of acute stroke and to identify patients at high risk of sudden death.

Comparison of two depression measures for predicting stroke outcomes

OBJECTIVES

Little is known about the effect of lifetime history of depression on ischemic stroke outcomes. This study compared a measure of current symptoms of depression at the time of the stroke and a measure of lifetime history of depression for their ability to predict quality of life and functioning at 3 and 12 months after stroke.

METHODS

A cohort of 460 ischemic stroke patients from the 2005 Greater Cincinnati/North Kentucky Stroke Study was assessed within 2 weeks of the stroke, including the 10-item Center for Epidemiological Studies Depression Scale (CESD) for current symptoms of depression. Lifetime history of depression was also assessed by a 2-question measure at 3 and 12 months after stroke. Two outcome measures, Stroke Specific Quality of Life (SSQOL) and the modified Rankin Scale (mRS) to assess functional status, were also collected at 3 and 12 months.

RESULTS

Of the 322 survivors included in the analysis, 52.2% reported depression on at least one measure. Both current symptoms and lifetime history of depression predicted poor functional outcomes and poor quality of life at 3 and 12 months, after adjustment for age, race, sex, prior stroke, baseline functional status, and stroke severity. The combination of depression measures was a better predictor of poor outcomes than either measure alone.

CONCLUSION

Depression by either measure was a frequent, substantial, and independent predictor of poor outcomes at 3 and 12 months after stroke. Stroke outcomes studies should further examine the predictive value of assessing both depressive symptoms at the time of the stroke and lifetime history of depression.

NIHSS and acute complications after anterior and posterior circulation strokes

Background

The purpose of this study was to determine whether the National Institutes of Health Stroke Scale (NIHSS) score was associated with inhospital neurological and medical complications (NMC) in patients with posterior circulation infarction.

Methods

This retrospective study included all patients admitted to our stroke unit during a one-year period (n = 289). NMC included neurological deterioration (ie, worsening by 4 points or more of the NIHSS score during the hospital stay) and all other medical complications based on what was recorded in the patients’ charts.

Results

Seventy-nine patients (27%) experienced NMC. In posterior circulation infarction patients (n = 90), patients with NMC had a higher baseline NIHSS score (10.9 versus 2.2, P = 0.004) and a baseline NIHSS score >2 (78% versus 36%, P = 0.003). In stepwise logistic regression, an NIHSS score >2 (odds ratio: 8.2; 95% confidence interval: 1.64–41.0; P = 0.01) was associated with NMC. Similar results were observed for anterior circulation infarction patients but with a higher cutoff value for NIHSS score.

Conclusion

In ischemic stroke patients, an increased baseline NIHSS score was associated with an increased risk of NMC. This association applied to anterior-circulation as well as posterior circulation stroke, although zero on the NIHSS for posterior circulation stroke does not mean the absence of NMC during hospitalization. The clinical significance of these findings requires further evaluation in larger prospective studies.

Luteolin downregulates TLR4, TLR5, NF-κB and p-p38MAPK expression, upregulates the p-ERK expression, and protects rat brains against focal ischemia

BACKGROUND

Inflammatory damage is known to be involved in ischemic stroke. Luteolin has been proved to elicit a series of biologic effects through its anti-inflammatory property in multiple sclerosis and rheumatoid arthritis. Whether this protective effect applies to ischemic injury in brain is still unknown, we therefore investigate the potential neuroprotective role of luteolin in ischemic stroke and the underlying mechanisms.

METHODS

Male Sprague-Dawley rats were subjected to pMCAO and luteolin was administered intraperitoneally immediately after surgery, then once daily thereafter. Neurological deficit, infarct volume, and brain water content were measured at 24 h and 72 h after stroke. The expression of TLR4, TLR5, and NF-κB were measured by real-time PCR, immunohistochemical staining (IHC), and Western blot. P38MAPK and extracellular signal-regulated kinase (ERK) were detected by IHC, and Western blot.

RESULTS

Compared with pMCAO group, luteolin significantly alleviated neurological deficit, decreased infarct volume and suppressed edema after ischemic stroke, which were accompanied with decreased expression of TLR4, TLR5, NF-κB and p-p38MAPK. Meanwhile, luteolin activated the expression of p-ERK1/2 (P<0.05).

CONCLUSIONS

Luteolin protected the brain from the damage caused by pMCAO, and this effect may be through downregulation of TLR4, TLR5, NF-κB, p38MAPK and upregulation of ERK expression.