Age-dependent differences in demographics, risk factors, co-morbidity, etiology, management, and clinical outcome of acute ischemic stroke

Stroke Rehabilitation in India: Addressing Gender Inequities

Gender inequality has a significant and complex impact on stroke recovery and rehabilitation outcomes. Moreover, the influence of gender on post-stroke recovery is multifactorial, primarily biological, social, and behavioral issues. The recovery paths for men and women may have different outlines in relation to stroke occurrence, injury sites, and hormonal effects. These collectively influence the effective summarization of recovery strategies and outcomes. Furthermore, societal and cultural elements play a significant role in shaping access to resources, social support networks, and participation in rehabilitation programs, which consequently affect the outcomes. Considering the gender-specific nuances is important in developing effective rehabilitation strategies. Furthermore, effective stroke rehabilitation programs are needed to achieve equitable and improved recovery outcomes for all stroke survivors and to create inclusive interventions that consider these differences.

Disparity in risk factors of ischemic stroke in four coastal-area hospitals in China

Background

Currently, ischemic stroke is the leading cause of death in China. To compare regional differences of ischemic stroke, we analyzed the clinical characteristics of patients with ischemic stroke in four regionally representative hospitals in China.

Methods

We conducted a retrospective study at four tertiary hospitals in east China, with regionally representative patients. The associated factors include hypertension, diabetes mellitus, coronary heart disease, hyperlipidemia and a combination of these factors. The standardized ratio (SR), estimated as the observed number divided by the expected number, computed as the sum of predicted probabilities from a multivariable logistic regression model derived using data from all other cities, was used to compare to average levels.

Results

A total of 34,707 patients were included. The number of patients increased with age in all four hospitals and patients were predominantly male. The number of ischemic stroke cases with related factors increased with age, except for hyperlipidemia. There was no significant gender difference when multiple related factors existed simultaneously. Coronary heart disease had a more significant impact on ischemic stroke in Qingdao Municipal Hospital and the First Hospital of Qinhuangdao, while hyperlipidemia had a significant influence on ischemic stroke in the First Hospital of Qinhuangdao.

Conclusions

At four hospitals in east China, with the increase of age, the risk factors associated with ischemic stroke increased, and the distribution of ischemic stroke-related factors showed regional differences.

Cerebrovascular Events and Hospital Discharge Outcomes Associated With Drug Use: A Retrospective Case-Matched Study

Introduction Individuals using cocaine, methamphetamines, cannabis, and other mood-altering drugs (MADs) have been reported to have greater stroke risk when compared to individuals who do not use these drugs. Yet, the impact that MAD use has on stroke outcomes has not been adequately explored, with existing research not agreeing on the extent to which the use of these drugs influences stroke outcomes. This study aimed to determine the impact that the use of common MADs has on stroke outcome factors such as length of stay (LOS), discharge modified Rankin Scale (mRS), and discharge disposition. Methods A retrospective case-matched study was conducted with two adult cohorts treated for cerebrovascular accidents: those who use MADs and those who do not use MADs prior to their stroke. Subjects identified for the users of MADs cohort were matched at a 1:1 ratio to those who do not use MADs (control cohort) by age, sex, and stroke type (e.g., hemorrhagic or ischemic). Logistic regression was used to calculate odds ratios for functional outcomes for stroke patients with and without prior MAD use. Results Active users of MADs had an increased overall risk of poor stroke outcome, i.e., increased length of stay, discharge disposition other than to home or to rehabilitation, discharge modified Rankin scale (mRS) 3-6 after controlling for stroke severity from initial National Institutes of Health Stroke Scale (NIHSS) (X2{9}=21.68, p<0.01, Cox adjusted R2=0.31). This finding was driven predominately by increased hospital LOS (p=0.006) among the MAD cohort, whereas discharge mRS 3-6 (p=0.24) and discharge disposition to care facility (p=0.27) and expired (p=0.26) did not vary significantly between groups. Conclusion Our study suggests that patients who had actively used MADs prior to their stroke may be at risk of poorer stroke outcomes, namely an increased LOS. Future research should be conducted to further elucidate which factors, such as individual drugs, amount of drug, acute or recreational use versus chronic or long-term use, and route of administration, for instance, specifically contribute to a longer LOS so that they may be targeted for mitigation.

S100B and brain ultrasound: Novel predictors for functional outcome in acute ischemic stroke patients

OBJECTIVE

Stroke is a leading cause of mortality and disability worldwide. This study aimed to assess the prognostic value of serum S100B protein, transcranial color-coded duplex sonography (TCCD), and optic nerve sheath diameter (ONSD) in predicting functional outcomes in critically ill patients with acute ischemic stroke (AIS).

METHODS

In this prospective observational study, 80 adult AIS patients were evaluated. Serum S100B protein levels, ONSD, and middle cerebral artery pulsatility index (MCA PI) were measured on days 1 and 3. Functional outcomes at 90 days were assessed using the modified Rankin Scale (mRS) and categorized into favourable (mRS 0-2) or unfavourable (mRS 3-6) groups. The association of demographic, clinical, laboratory, and imaging parameters with mRS outcomes was analyzed.

RESULTS

Poor mRS outcomes occurred in 82.5 % of patients. Factors significantly associated with poor outcomes were female sex, higher National Institutes of Health Stroke Scale (NIHSS) scores on days 1, 3, and 7, and larger stroke size. Receiver Operating Characteristic (ROC) curve analysis revealed that ONSD at days 1 and 3, serum S100B levels at day 1, and right MCA PI at day 1 had significant predictive value for poor mRS outcome. Multivariate analysis identified female sex, S100B on day 1, and NIHSS on days 1, 3, and 7 as independent predictors of poor mRS outcomes.

CONCLUSIONS

The combination of S100B, ONSD, and MCA PI improved the prediction of functional outcomes in critically ill AIS patients. Early S100B measurement and brain ultrasound evaluation may serve as valuable prognostic tools for guiding therapeutic decision-making. This study provides novel insights into the role of S100B and brain ultrasound in stroke outcome prediction, particularly in critically ill AIS patients.

Sex Differences in Functional Capacity in Older Adults With Stroke: An Analysis of Data From the National Health and Aging Trends Study

OBJECTIVE

Women experience greater disability following stroke, but biological sex differences in both overall and specific domains of functional capacity are not well understood. The primary objective of this study was to examine sex differences in overall functional capacity (Short Physical Performance Battery [SPPB] score) cross-sectionally and longitudinally over a 3-year follow-up period. The secondary objective was to determine whether sex differences exist in specific domains of functional capacity of walking speed and lower extremity functional strength.

METHODS

This study was a secondary analysis of data of individuals with stroke from the National Health and Aging Trends Study. For the cross-sectional analyses, general linear models were used to examine differences between 293 men and 427 women in SPPB, walking speed, and the 5-Times Sit-to-Stand Test (5XSST). For the longitudinal analysis, survey-weighted, multivariable-adjusted generalized linear mixed models were used to compare 3-year trajectories in SPPB scores between the sexes (87 men, 153 women).

RESULTS

Women had lower SPPB scores at baseline (difference = 0.9, linearized SE = 0.3) and over 3 years. SPPB scores declined similarly between men and women. Women had lower walking speed (difference = 0.08 m/s, SE = 0.02) as compared with men, but men and women had similar 5XSST scores (difference = 0.6 seconds, SE = 0.5).

CONCLUSION

Older women with stroke have clinically meaningfully lower overall functional capacity as compared with older men but decline at a similar rate over time. Walking speed was lower in older women with stroke, but similar between sexes in 5XSST.

IMPACT

Women with stroke have poorer functional capacity compared with men, which reinforces the importance of targeted stroke rehabilitation strategies to address these sex-specific disparities.

LAY SUMMARY

Women with stroke have poorer outcomes in terms of their ability to move around the community when compared with men. However, both men and women with stroke have similar physical functioning over time.

Thrombolysis, time-to-treatment and in-hospital outcomes among young adults with ischaemic stroke in China: findings from a nationwide registry study in China

BACKGROUND AND PURPOSE

We aimed to determine whether young adults (<50 years) with acute ischaemic stroke (AIS) are more likely to receive intravenous tissue plasminogen activator (IV tPA) and have shorter time to treatment than older patients with stroke.

METHODS

We analysed data from the Chinese Stroke Center Alliance registry for patients with AIS hospitalised between August 2015 and July 2019. Patients were classified into two groups according to age: young adults (<50 years of age) and older adults (≥50 years of age).

RESULTS

Of 793 175 patients with AIS admitted to 1471 hospitals, 9.1% (71 860) were young adults. Compared with older adults, a higher proportion of young adults received IV tPA among patients without contraindicaitons (7.2% vs 6.1%, adjusted OR (aOR) 1.13, 95% CI 1.10 to 1.17) and among patients without contraindications and with onset-to-door time ≤3.5 hours (23.6% vs 19.3%, aOR 1.20, 95% CI 1.15 to 1.24). We did not observe differences in onset-to-needle time (median hours 2.7 hours) or door-to-needle time (DNT) (median minutes 60 min) between young and older adults. The proportion of DNT ≤30 min, DNT ≤45 min and DNT ≤60 min in young and older IV tPA-treated patients were 16.9% vs 18.8%, 30.2% vs 32.8% and 50.2% vs 54.2%, respectively. Compared with older adults, young adults treated with IV tPA had lower odds of in-hospital mortality (0.5% vs 1.3%, aOR 0.54, 95% CI 0.35 to 0.82) and higher odds of independent ambulation at discharge (61.0% vs 53.6%, aOR 1.15, 95% CI 1.08 to 1.22), and the associations may be partly explained by stroke severity measured by the National Institutes of Health Stroke Scale score.

CONCLUSION

Young adults with AIS were more likely to receive IV tPA than older adults, although there was no difference between the two groups in time to treatment. Compared with older adults, young adults may had better in-hospital outcomes.

Community planning for a "healthy built environment" via a human-environment nexus? A multifactorial assessment of environmental characteristics and age-specific stroke mortality in Hong Kong

With the prevalence of stroke rising due to both aging societies and more people getting strokes at a younger age, a comprehensive investigation into the relationship between urban characteristics and age-specific stroke mortality for the development of a healthy built environment is necessary. Specifically, assessment of various dimensions of urban characteristics (e.g. short-term environmental change, long-term environmental conditions) is needed for healthy built environment designs and protocols. A multifactorial assessment was conducted to evaluate associations between environmental and sociodemographic characteristics with age-stroke mortality in Hong Kong. We found that short-term (and temporally varying) daily PM₁₀, older age and being female were more strongly associated with all types of stroke deaths compared to all-cause deaths in general. Colder days, being employed and being married were more strongly associated with hemorrhagic stroke deaths in general. Long-term (and spatially varying) regional-level air pollution were more strongly associated with non-hemorrhagic stroke deaths in general. These associations varied by age. Employment (manual workers) and low education were risk factors for stroke mortality at younger ages (age <65). Greenness and open space did not have a significant association with stroke mortality. Since a significant connection was expected, this leads to questions about the health-inducing efficacy of Hong Kong's compact open spaces (natural greenery being limited to steep slopes, and extensive impervious surfaces on public open spaces). In conclusion, urban plans and designs for stroke mortality prevention should implement age-specific health care to neighborhoods with particular population segments.

Neuroinflammation as a Key Driver of Secondary Neurodegeneration Following Stroke?

Ischaemic stroke involves the rapid onset of focal neurological dysfunction, most commonly due to an arterial blockage in a specific region of the brain. Stroke is a leading cause of death and common cause of disability, with over 17 million people worldwide suffering from a stroke each year. It is now well-documented that neuroinflammation and immune mediators play a key role in acute and long-term neuronal tissue damage and healing, not only in the infarct core but also in distal regions. Importantly, in these distal regions, termed sites of secondary neurodegeneration (SND), spikes in neuroinflammation may be seen sometime after the initial stroke onset, but prior to the presence of the neuronal tissue damage within these regions. However, it is key to acknowledge that, despite the mounting information describing neuroinflammation following ischaemic stroke, the exact mechanisms whereby inflammatory cells and their mediators drive stroke-induced neuroinflammation are still not fully understood. As a result, current anti-inflammatory treatments have failed to show efficacy in clinical trials. In this review we discuss the complexities of post-stroke neuroinflammation, specifically how it affects neuronal tissue and post-stroke outcome acutely, chronically, and in sites of SND. We then discuss current and previously assessed anti-inflammatory therapies, with a particular focus on how failed anti-inflammatories may be repurposed to target SND-associated neuroinflammation.

Direct Endovascular Thrombectomy Alone vs. Bridging Thrombolysis for Patients with Acute Ischemic Stroke : A Meta-analysis

PURPOSE

Although the current guidelines recommend bridging thrombolysis (BT) therapy, which is intravenous thrombolysis (IVT) followed by endovascular thrombectomy (EVT), for patients with acute ischemic stroke from large vessel occlusion (AIS-LVO), the effectiveness and safety of IVT remain controversial. We performed a meta-analysis to demonstrate the non-inferiority of direct EVT alone (DEVT) compared to BT for the efficacy and safety in patients with AIS-LVO who were eligible for IVT.

METHODS

The literature was searched in big databases between 1 January 1990 and 1 April 2021. The search included both randomized clinical trials (RCTs) and nonrandomized studies (NRSs) that compared DEVT with BT for patients with AIS-LVO who were eligible for IVT (time from stroke onset ≤ 4.5 h). Only NRSs with good intergroup variable matching were included in the study. Outcomes measured included 90-day functional independence, mortality, symptomatic intracranial hemorrhage (sICH), and successful recanalization. The noninferiority margin for risk difference was set at 5% from the literature review.

RESULTS

Three RCTs (n = 1094) and four NRSs (n = 1366) were included in the meta-analysis. There were 1227 patients (49.9%) in the DEVT group and 1233 patients (50.1%) in the BT group. A statistically significant noninferiority of DEVT compared to BT was concluded in 90-day functional independence, mortality and successful reperfusion. Even in the sICH rate, DEVT group showed a superiority (risk difference, -2%; 95% confidence interval, -4 to -0.002%).

CONCLUSION

Evidence from RCTs and observational NRSs supports the use of DEVT (without IVT) as the first choice for treatment of patients with AIS-LVO within a time span of 4.5 h or less from stroke onset.

Age in relation to comorbidity and outcome in patients with high-risk TIA or minor ischemic stroke: A Swedish national observational study

Introduction

Recent trials report positive results for preventing vascular events with dual antiplatelet therapy (DAPT) in patients with high-risk TIA or minor ischemic stroke. We aimed to investigate this population regarding influence of age on vascular risk factors, hospital stay and mortality.

Patients and methods

Data on patients aged 40-100 years with TIA or ischemic stroke in the Swedish Stroke Register during 2012-13 were linked with national registers. To identify patients with high-risk TIA (ABCD² ≥6) or minor ischemic stroke (NIHSS ≤5) eligible for DAPT, we excluded patients with atrial fibrillation, anticoagulant use, prior major bleeding, or unknown stroke severity.

Findings

We identified 10,053 potential DAPT-candidates (mean age 72.6 years, 45.2% female, 16.4% with TIA). With advancing age, most vascular risk factors increased. Antiplatelet treatment increased from 31.9% before the event to 95.5% after discharge. Within 1 year following index event, the proportion of patients with ≥1 re-admission increased with age (29.2% in 40-64 year-olds; 47.2% in 85-100 year-olds). All-cause death per 100 person-years was 6.9 (95% CI 6.4-7.4) within 1 year, and highest in the first 30 days (15.2; 95% CI 12.8-18.2). For each year of increased age, the risk of death increased with 3.5% (p = 0.128) in patients 40-64 years and with 11.8% (p < 0.001) in those ≥85 years.

Conclusions

While in theory representing a subset of patients with mild injury, our observational study highlights substantial use of health-care resources and high mortality rates among patients with high-risk TIA or minor ischemic stroke assumed eligible for DAPT.

[Indicators of homeostasis, inflammation and homocysteine in ischemic stroke in the young age]

AIM

To determine indicators of homeostasis, inflammation and homocysteine in the young-aged patients with ischemic stroke (IS) of different genesis in the subacute and chronic stages.

MATERIAL AND METHODS

Out of 218 patients with IS (mean age 34.7±8.7 years), 55 had stroke due to dissection of the inner carotid or the spinal artery, 28 due to cardioembolia, 38 due to antiphospholipid syndrome (APS), 16 due to cerebral arteritis; 85 patients were classified as having cryptogenic stroke, including 23 with noncerebral thrombosis (coagulopathy of unknown etiology) and 62 with no thrombosis. The control group included 28 healthy people matched for age and sex.

RESULTS

There were 1) an increase in von Willebrand factor and coagulation factor VIII as well as a decrease in plasminogen and an increase in plasmin-inhibitor in IS caused by thrombosis (APS, cardioembolia, coagulopathy of unknown etiology); 2) alterations in erythrocyte aggregation and deformity in cryptogenic stroke; 3) mild or moderate hyperhomocysteinemia, with the exception of patients with APS and arteritis. Linear regression analysis confirmed these relationships. Discriminant analysis identified the clusters of parameters characteristic of APS (an increase in (aPTT), plasminogen, blood sedimentation rate, C-reactive protein) and cardioembolia (decreased protein C and increased hematocrit).

CONCLUSION

The laboratory markers associated with cerebral thrombosis can be used for identification of a prothrombotic state as a cause of IS in the young age. Moderate hyperhomocysteinemia is a risk factor but not a cause of IS. The increase of inflammatory markers in APS suggests a role of infection in its development.

Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis

BACKGROUND

Whether pretreatment with intravenous thrombolysis prior to mechanical thrombectomy (IVT+MTE) adds additional benefit over direct mechanical thrombectomy (dMTE) in patients with large vessel occlusions (LVO) is a matter of debate.

METHODS

This study-level meta-analysis was presented in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled effect sizes were calculated using the inverse variance heterogeneity model and displayed as summary Odds Ratio (sOR) and corresponding 95% confidence interval (95% CI). Sensitivity analysis was performed by distinguishing between studies including dMTE patients eligible for IVT (IVT-E) or ineligible for IVT (IVT-IN). Primary outcome measures were functional independence (modified Rankin Scale≤2) and mortality at day 90, successful reperfusion, and symptomatic intracerebral hemorrhage.

RESULTS

Twenty studies, incorporating 5279 patients, were included. There was no evidence that rates of successful reperfusion differed in dMTE and IVT+MTE patients (sOR 0.93, 95% CI 0.68 to 1.28). In studies including IVT-IN dMTE patients, patients undergoing dMTE tended to have lower rates of functional independence and had higher odds for a fatal outcome as compared with IVT+MTE patients (sOR 0.78, 95% CI 0.61 to 1.01 and sOR 1.45, 95% CI 1.22 to 1.73). However, no such treatment group effect was found when analyses were confined to cohorts with a lower risk of selection bias (including IVT-E dMTE patients).

CONCLUSION

The quality of evidence regarding the relative merits of IVT+MTE versus dMTE is low. When considering studies with lower selection bias, the data suggest that dMTE may offer comparable safety and efficacy as compared with IVT+MTE. The conduct of randomized-controlled clinical trials seems justified.

A Hospital-Based Study of Stroke in Young from North East India

Introduction:

A study of stroke among young adults and children has recently become a subject of interest. This is because it has a major impact on the individual and society. Studies of stroke in young can lead to therapeutical results affecting both short- and long-term outcomes.

Methods:

This paper is based on a hospital-based retrospective study, of stroke in young, for a duration of 1 year.

Results:

The study revealed stroke in young in 31.38% of all strokes, with cerebral infarction in 50.66%, followed by intracerebral hemorrhage in 41.33%, subarachnoid hemorrhage in 4.66%, and cerebral venous thrombosis in 3.33%. The most common presenting symptom was hemiparesis. The most prevalent risk factor for stroke in young was alcohol consumption, followed by traditional risk factors such as hypertension and smoking. Diabetes was detected less in our study.

Conclusion:

Although traditional risk factors are associated with stroke in young, unfavorable behavioral pattern such as alcohol abuse may cause and promote development stroke in young.

Risk factors and mortality associated with multimorbidity in people with stroke or transient ischaemic attack: a study of 8,751 UK Biobank participants

BACKGROUND

Multimorbidity is common in stroke, but the risk factors and effects on mortality remain poorly understood.

OBJECTIVE

To examine multimorbidity and its associations with sociodemographic/lifestyle risk factors and all-cause mortality in UK Biobank participants with stroke or transient ischaemic attack (TIA).

DESIGN

Data were obtained from an anonymized community cohort aged 40-72 years. Overall, 42 comorbidities were self-reported by those with stroke or TIA. Relative risk ratios demonstrated associations between participant characteristics and number of comorbidities. Hazard ratios demonstrated associations between the number and type of comorbidities and all-cause mortality. Results were adjusted for age, sex, socioeconomic status, smoking, and alcohol intake. Data were linked to national mortality data. Median follow-up was 7 years.

RESULTS

Of 8,751 participants (mean age 60.9±6.7 years) with stroke or TIA, the all-cause mortality rate over 7 years was 8.4%. Over 85% reported ≥1 comorbidities. Age, socioeconomic deprivation, smoking and less frequent alcohol intake were associated with higher levels of multimorbidity. Increasing multimorbidity was associated with higher all-cause mortality. Mortality risk was double for those with ≥5 comorbidities compared to those with none. Having cancer, coronary heart disease, diabetes, or chronic obstructive pulmonary disease significantly increased mortality risk. Presence of any cardiometabolic comorbidity significantly increased mortality risk, as did any non-cardiometabolic comorbidity.

CONCLUSIONS

In stroke survivors, the number of comorbidities may be a more helpful predictor of mortality than type of condition. Stroke guidelines should take greater account of comorbidities, and interventions are needed that improve outcomes for people with multimorbidity and stroke.

Intermediate risk of cardiac events and recurrent stroke after stroke admission in young adults

Background

In older adults with stroke, there is an increased risk of cardiovascular events in the intermediate period, up to one year after stroke. The risk of cardiovascular events in this period in young adults after stroke has not been studied. We hypothesized that in the intermediate risk period, young adults with ischemic stroke have an increased risk of recurrent stroke and a smaller increase of cardiac events.

Methods

Using the National Readmissions Database during the year 2013, we identified ischemic stroke admissions among those aged 18–45 years using International Classification of Disease, Ninth Revision, Clinical Modification codes to identify index vascular events and risk factors. Primary outcomes were readmission for cardiac events and stroke. Multivariable Cox proportional hazard models and Kaplan–Meier analysis were used to estimate risk of primary outcomes.

Results

We identified 12,392 young adults with index stroke. The readmission rate due to recurrent stroke was higher than for cardiac events (2913.3.1 vs. 1132.4 per 100,000 index hospitalizations at 90 days). There was a higher cumulative risk of both cardiac events and recurrent stroke in the presence of baseline diabetes and hypercholesterolemia.

Conclusion

In a large, nationally representative database, the intermediate risk of recurrent stroke after index stroke in young adults was higher than the risk of cardiac events. The presence of vascular risk factors augmented this risk but did not entirely account for it. The aggressive control of hypercholesterolemia and diabetes may play an important role in secondary prevention in young adults with stroke.

Multimorbidities Are Associated to Lower Survival in Ischaemic Stroke: Results from a Brazilian Stroke Cohort (EMMA Study)

BACKGROUND

Stroke prognosis is related to the multimorbidity profile. Moreover, performing an individual evaluation of most common cerebrovascular risk factors (CVRF) not always identifies patients with poor prognosis. Thus, we decided to evaluate multimorbidity profile, focusing on the Charlson Comorbidity Index (CCI) validated by Goldstein for ischaemic stroke (IS) patients, a score that measures a burden of comorbidities and its related mortality in the long-term survival of the EMMA Study (Study of Stroke Mortality and Morbidity).

METHODS

Nine hundred fifty-nine individuals (median age 70 years) had validated data on the diagnosis of IS, main CVRF and clinical comorbidities pre index event such as atrial fibrillation (AF), stroke recurrence, diabetes, hypertension, heart failure and cancer. CCI modified by Goldstein was calculated, which includes 17 clinical conditions with scores ranging from 1 to 6 (0-31 points). Survival analyses were performed by Kaplan-Meier curves and Cox logistic regression models (cumulative hazard ratio [HR] with [95% CI]) for all-cause mortality at 180 days, and every 3 years up to 9-year follow-up. Mortality analyzes were performed by CCI categorized according to weight added to comorbidities (Reference group: zero, moderate: 1, severe: 2 and very severe: ≥3 points). We also tested the modification effect of AF and stroke recurrence including these conditions in the CCI.

RESULTS

The overall survival rate was 47% (508 deaths/959). The worst survival (577, 95% CI 381-773 days) and the highest risk of death after stroke were observed in the very severe CCI group (HR 3.18; 95% CI 2.16-4.69) up to 9 years. The inclusion of previous AF and stroke in the CCI slightly increased the risk of death for very severe CCI (HR 3.27; 95% CI 2.07-5.18).

CONCLUSIONS

A high burden of comorbidities represented an independent predictor of poor prognosis increasing the risk of dying by 2 to 3 times among IS up to 9 years in the EMMA study. The inclusion of other CVRF such as AF and stroke recurrence slightly modified all-cause mortality risk.

Contralateral Superior Cerebellar Artery Syndrome: A Consequence of Brain Herniation

Vascular compromise is a well-known consequence of brain herniation syndromes. Transtentorial brain herniation most often involves posterior cerebral arteries. However, isolated involvement of contralateral superior cerebellar artery (SCA) during unilateral impending brain herniation is reported only once and we present another case of this exceedingly rare entity. A 24-year-old man was referred to us with impending herniation due to a multiloculated hydrocephalus, and during the course of illness, he developed an isolated SCA ischemia in the opposite side of the most dilated entrapped horn. In the current article we discuss the probable pathophysiologic mechanisms of this phenomenon, as well as recommending more inclusive brain studies in cases suspected of Kernohan-Woltman notch phenomenon in unilateral brain herniation. The rationale for this commentary is that contralateral SCA transient ischemia or infarct might be the underdiagnosed underlying pathomechanism of ipsilateral hemiparesis occurring in many cases of this somehow vague phenomenon.

A narrative review of the impact of medical comorbidities on stroke rehabilitation outcomes

PURPOSE

Medical comorbidities in stroke patients influence acute mortality, but may also affect participation of survivors in rehabilitation. There is limited research investigating the impact of comorbidities on stroke rehabilitation outcomes. The review will explore the literature on the impact of comorbidities on stroke rehabilitation outcome.

MATERIALS AND METHODS

The literature was searched systematically, including MEDLINE database, EMBASE and PsychINFO, combining variations of the terms stroke, rehabilitation and comorbidities. Results were limited to English language publications. Included studies had a functional outcome.

RESULTS

Twenty relevant articles were identified. Fifteen small prospective or large retrospective studies using global comorbidity scales produced conflicting relationships between comorbidities and rehabilitation outcomes. Five publications addressed specific comorbidities, with three studies finding negative correlation between diabetes and rehabilitation outcomes, although effects diminished with age. In general, there were discrepancies in how comorbidities were identified. Few studies specifically focused on comorbidities and/or rehabilitation outcomes.

CONCLUSIONS

There is conflicting evidence regarding the impact of comorbidities on stroke rehabilitation outcomes. However, the presence of more severe diabetes may be associated with worse outcomes. The role of comorbidities in stroke rehabilitation would be best clarified with a large cohort study, with precise comorbidity identification measured against rehabilitation specific outcomes. Implications for rehabilitation Benefit of rehabilitation after stroke in improving functional outcome is well-established. Many stroke patients have comorbid conditions which can impact rehabilitation participation, leading to less benefit obtained from rehabilitation. The burden of comorbid conditions may slow rehabilitation progress, which may warrant a longer duration of rehabilitation to obtain required functional gain to be discharged into the community.

Sex Differences and Functional Outcome After Intravenous Thrombolysis

Background and Purpose—

Women have a worse outcome after stroke compared with men, although in intravenous thrombolysis (IVT)–treated patients, women seem to benefit more. Besides sex differences, age has also a possible effect on functional outcome. The interaction of sex on the functional outcome in IVT-treated patients in relation to age remains complex. The purpose of this study was to compare outcome after IVT between women and men with regard to age in a large multicenter European cohort reflecting daily clinical practice of acute stroke care.

Methods—

Data were obtained from IVT registries of 12 European tertiary hospitals. The primary outcome was poor functional outcome, defined as a modified Rankin scale score of 3 to 6 at 3 months. We stratified outcome by age in decades. Safety measures were symptomatic intracranial hemorrhage and mortality at 3 months.

Results—

In this cohort, 9495 patients were treated with IVT, and 4170 (43.9%) were women with a mean age of 71.9 years. After adjustments for baseline differences, female sex remained associated with poor functional outcome (odds ratio, 1.15; 95% confidence interval, 1.02–1.31). There was no association between sex and functional outcome when data were stratified by age. Symptomatic intracranial hemorrhage rate was similar in both sexes (adjusted odds ratio, 0.93; 95% confidence interval, 0.73–1.19), whereas mortality was lower among women (adjusted odds ratio, 0.83; 95% confidence interval, 0.70–0.99).

Conclusions—

In this large cohort of IVT-treated patients, women more often had poor functional outcome compared with men. This difference was not dependent on age.

Is poststroke complex regional pain syndrome the combination of shoulder pain and soft tissue injury of the wrist?: A prospective observational study: STROBE of ultrasonographic findings in complex regional pain syndrome

Patients with poststroke complex regional pain syndrome (CRPS) show different symptoms compared to other types of CRPS, as they usually complain of shoulder and wrist pain with the elbow relatively spared. It is thus also known by the term "shoulder-hand syndrome."The aim of this study is to present a possible pathophysiology of poststroke CRPS through ultrasonographic observation of the affected wrist before and after steroid injection at the extensor digitorum communis (EDC) tendon in patients suspected with poststroke CRPS.Prospective evaluation and observation, the STROBE guideline checklist was used.Twenty-three patients diagnosed as poststroke CRPS in accordance to clinical criteria were enrolled. They had a Three Phase Bone Scan (TPBS) done and the cross-sectional area (CSA) of EDC tendon was measured by using ultrasonography. They were then injected with steroid at the EDC tendon. The CSA of EDC tendon, visual analogue scale (VAS), and degree of swelling of the wrist were followed up 1 week after the injection.TPBS was interpreted as normal for 4 patients, suspected CRPS for 10 patients, and CRPS for 9 patients. Ultrasonographic findings of the affected wrist included swelling of the EDC tendon. After the injection of steroid to the wrist, CSA and swelling of the affected wrist compared to that before the treatment was significantly decreased (P < 0.001). The VAS score declined significantly after the injection (P < 0.001).Our results suggest that the pathophysiology of poststroke CRPS might be the combination of frozen shoulder or rotator cuff tear of shoulder and soft tissue injury of the wrist caused by the hemiplegic nature of patients with stroke.

A 6-Point TACS Score Predicts In-Hospital Mortality Following Total Anterior Circulation Stroke

Background and Purpose

Little is known about the factors associated with in-hospital mortality following total anterior circulation stroke (TACS). We examined the characteristics and comorbidity data for TACS patients in relation to in-hospital mortality with the aim of developing a simple clinical rule for predicting the acute mortality outcome in TACS.

Methods

A routine data registry of one regional hospital in the UK was analyzed. The subjects were 2,971 stroke patients with TACS (82% ischemic; median age=81 years, interquartile age range=74–86 years) admitted between 1996 and 2012. Uni- and multivariate regression models were used to estimate in-hospital mortality odds ratios for the study covariates. A 6-point TACS scoring system was developed from regression analyses to predict in-hospital mortality as the outcome.

Results

Factors associated with in-hospital mortality of TACS were male sex [adjusted odds ratio (AOR)=1.19], age (AOR=4.96 for ≥85 years vs. <65 years), hemorrhagic subtype (AOR=1.70), nonlateralization (AOR=1.75), prestroke disability (AOR=1.73 for moderate disability vs. no symptoms), and congestive heart failure (CHF) (AOR=1.61). Risk stratification using the 6-point TACS Score [T=type (hemorrhage=1 point) and territory (nonlateralization=1 point), A=age (65–84 years=1 point, ≥85 years=2 points), C=CHF (if present=1 point), S=status before stroke (prestroke modified Rankin Scale score of 4 or 5=1 point)] reliably predicted a mortality outcome: score=0, 29.4% mortality; score=1, 46.2% mortality [negative predictive value (NPV)=70.6%, positive predictive value (PPV)=46.2%]; score=2, 64.1% mortality (NPV=70.6, PPV=64.1%); score=3, 73.7% mortality (NPV=70.6%, PPV=73.7%); and score=4 or 5, 81.2% mortality (NPV=70.6%, PPV=81.2%).

Conclusions

We have identified the key determinants of in-hospital mortality following TACS and derived a 6-point TACS Score that can be used to predict the prognosis of particular patients.

Why is it difficult to predict language impairment and outcome in patients with aphasia after stroke?

One of the most devastating consequences of stroke is aphasia. Communication problems after stroke can severely impair the patient's quality of life and make even simple everyday tasks challenging. Despite intense research in the field of aphasiology, the type of language impairment has not yet been localized and correlated with brain damage, making it difficult to predict the language outcome for stroke patients with aphasia. Our primary objective is to present the available evidence that highlights the difficulties of predicting language impairment after stroke. The different levels of complexity involved in predicting the lesion site from language impairment and ultimately predicting the long-term outcome in stroke patients with aphasia were explored. Future directions and potential implications for research and clinical practice are highlighted.

The effects of estrogen in ischemic stroke

Stroke is a leading cause of death and the most common cause of long-term disability in the USA. Women have a lower incidence of stroke compared with men throughout most of the lifespan which has been ascribed to protective effects of gonadal steroids, most notably estrogen. Due to the lower stroke incidence observed in pre-menopausal women and robust preclinical evidence of neuroprotective and anti-inflammatory properties of estrogen, researchers have focused on the potential benefits of hormones to reduce ischemic brain injury. However, as women age, they are disproportionately affected by stroke, coincident with the loss of estrogen with menopause. The risk of stroke in elderly women exceeds that of men and it is clear that in some settings estrogen can have pro-inflammatory effects. This review will focus on estrogen and inflammation and its interaction with aging.

Stroke subtype predicts outcome in young and middle-aged stroke sufferers

OBJECTIVES

There are few studies on long-term outcome after ischemic stroke (IS) for young and middle-aged stroke sufferers in relation to etiologic subtypes. Here, we report 2-year outcome in the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS).

MATERIALS AND METHODS

SAHLSIS comprises 600 patients with IS before the age of 70 years. Etiologic subtype of IS was classified according to Trial of Org 10172 in Acute Stroke Treatment (TOAST). Recurrent vascular events and death were registered using several overlapping methods. Functional outcome was assessed according to the modified Rankin Scale (mRS).

RESULTS

After 2 years, 55 (9.2%) patients had suffered a recurrent stroke, 15 (2.5%) had a transient ischemic attack (TIA), 4 (0.7%) had a coronary event, and 24 (4.0%) had died. The number of recurrent stroke, TIA, and death differed significantly between etiologic stroke subtypes. The highest rates were observed in large-vessel disease (LVD), whereas small-vessel disease and cryptogenic stroke showed the lowest recurrence and mortality rates. LVD was a significant predictor of the composite outcome (recurrent stroke, TIA, coronary event and/or death) independently of cardiovascular risk factors and stroke severity. Stroke subtype also predicted functional outcome 2 years after index stroke, but this association was not retained after adjustment for stroke severity.

CONCLUSIONS

In young and middle-aged stroke patients, stroke subtype predicts recurrent vascular events and/or death 2 years after index stroke independently of cardiovascular risk factors and stroke severity. Thus, it is important to take the etiologic subtype of IS in account when assessing the risk of recurrence both in the clinical setting and in future studies.

Impact of Admission Glucose and Diabetes on Recanalization and Outcome after Intra-Arterial Thrombolysis for Ischaemic Stroke

Background

Stroke patients with diabetes and admission hyperglycaemia have worse outcomes than non-diabetics, with or without intravenous thrombolysis. Poor vessel recanalization was reported in diabetics treated with intravenous thrombolysis.

Aims

This study aimed to determine the impact of admission glucose and diabetes on recanalization and outcome after intra-arterial thrombolysis.

Methods

We analysed 389 patients (213 men, 176 women) treated with intra-arterial thrombolysis. The association of diabetes and admission glucose value with recanalization, outcome, mortality, and symptomatic intracranial haemorrhage was determined. Recanalization was classified according to thrombolysis in myocardial infarction grades. Outcome was measured using the modified Rankin Scale at three-months and categorized as favourable (modified Rankin Scale 0–2) or poor (modified Rankin Scale 3–6).

Results

The rate of partial or complete recanalization (thrombolysis in myocardial infarction 2–3) did not differ between patients with and without diabetes (67% vs. 66%; P = 1·000). Mean admission glucose values were similar in patients with poor recanalization (thrombolysis in myocardial infarction 0–1) and patients with partial or complete recanalization (thrombolysis in myocardial infarction 2–3; 7·3 vs. 7·3 mmol/l; P = 0·746). Follow-up at three-months was obtained in 388 of 389 patients. Clinical outcome was favourable (modified Rankin Scale 0–2) in 189 patients (49%) and poor (modified Rankin Scale 3–6) in 199 patients (51%). Mortality at three-months was 20%. Diabetics were more likely to have poor outcome (72% vs. 48%; P = 0·001) and to be dead (30% vs. 19%; P = 0·044) at three-months. After multivariable analysis, there remained an independent relationship between diabetes and outcome ( P = 0·003; odds ratio 3·033, 95% confidence interval 1·452–6·336), but not with mortality ( P = 0·310; odds ratio 1·436; 95% confidence interval 0·714–2·888). Moreover, higher age ( P = 0·001; odds ratio 1·039; 95% confidence interval 1·017–1·061), higher baseline National Institutes of Health Stroke Scale score ( P < 0·0001; odds ratio 1·130; 95% confidence interval 1·079–1·182), location of vessel occlusion as categorical variable ( P < 0·0001), poor collaterals ( P = 0·02; odds ratio 1·587; 95% confidence interval 1·076–2·341), poor vessel recanalization ( P < 0·0001; odds ratio 4·713; 95% confidence interval 2·627–8·454), and higher leucocyte count ( P = 0·032; odds ratio 1·094; 95% confidence interval 1·008–1·188) were independent baseline predictors of poor outcome. Higher admission glucose was associated with poor outcome ( P = 0·006) and mortality ( P < 0·0001). After multivariate analyses, glucose remained independently associated with poor outcome ( P = 0·019; odds ratio 1·150; 95% confidence interval 1·023-1-292) and mortality ( P = 0·005; odds ratio 1·183; 95% confidence interval 1052–1·331). The rate of symptomatic intracranial haemorrhage was similar in diabetics and non-diabetics (6·7% vs. 4·6%; P = 0·512). Mean admission glucose was higher in patients with symptomatic intracranial haemorrhage than without (8·58 vs. 7·26 mmol/l; P = 0·010). Multivariable analysis confirmed an independent association between admission glucose and symptomatic intracranial haemorrhage ( P = 0·027; odds ratio 1·187; 95% confidence interval 1·020–1·381).

Conclusions

Diabetes and glucose value on admission did not influence recanalization after intra-arterial thrombolysis; nevertheless, they were independent predictors of poor outcome after intra-arterial thrombolysis and a higher admission glucose value was an independent predictor of symptomatic intracranial haemorrhage. This indicates that factors on the capillary, cellular, or metabolic level may account for the worse outcome in patients with elevated glucose value and diabetes.

Towards more effective robotic gait training for stroke rehabilitation: a review

Background

Stroke is the most common cause of disability in the developed world and can severely degrade walking function. Robot-driven gait therapy can provide assistance to patients during training and offers a number of advantages over other forms of therapy. These potential benefits do not, however, seem to have been fully realised as of yet in clinical practice.

Objectives

This review determines ways in which robot-driven gait technology could be improved in order to achieve better outcomes in gait rehabilitation.

Methods

The literature on gait impairments caused by stroke is reviewed, followed by research detailing the different pathways to recovery. The outcomes of clinical trials investigating robot-driven gait therapy are then examined. Finally, an analysis of the literature focused on the technical features of the robot-based devices is presented. This review thus combines both clinical and technical aspects in order to determine the routes by which robot-driven gait therapy could be further developed.

Conclusions

Active subject participation in robot-driven gait therapy is vital to many of the potential recovery pathways and is therefore an important feature of gait training. Higher levels of subject participation and challenge could be promoted through designs with a high emphasis on robotic transparency and sufficient degrees of freedom to allow other aspects of gait such as balance to be incorporated.

Age differences in clinical characteristics, health care, and outcomes after ischemic stroke in China

BACKGROUND AND PURPOSE

Little information is available on the effects of age on health care and outcomes of ischemic stroke (IS) in China. Our aim was to evaluated risk factors, health care, and outcomes among age groups including ≤ 45, 46-65, 66-79, and ≥ 80 years and to find whether the outcome was affected by age and health care.

METHODS

CNSR is a nationwide prospective registry for patients admitted with acute stroke and prospectively followed up 12-month outcomes. Demographics, socioeconomics, risk factors, health care, and outcomes were analyzed among age groups, and multivariate regression analysis was used to determine the association of outcome and age and health care.

RESULTS

We identified 12,415 acute IS patients for analysis. Of 1179 (9.50%) were aged ≥ 80 years. In terms of risk factors, cardiac diseases were significantly more frequent in patients ≥ 80 years, behavioral risk factors were more common in younger patients, and hypertension, hyperlipidemia, and diabetes were more seen in 46-79 patients. The use of health care varied among groups and was significantly lower in ≥ 80 years especially in secondary prevention. The very old patients had the worst outcomes even after adjusting by prognostic factors; however, adjusting forward by health care, the extent of differences decreased.

CONCLUSIONS

In CNSR, differences in stroke clinic characteristics and health care were observed among various age groups, and the old patients, receiving lower levels of stroke care, had the worst outcomes. Knowledge of the age differences in ischemic stroke may be helpful to appropriately allocate the limited health resources and to improve stroke outcomes.

Neuroimaging in aphasia treatment research: quantifying brain lesions after stroke

New structural and functional neuroimaging methods continue to rapidly develop, offering promising tools for cognitive neuroscientists. In the last 20 years, advanced magnetic resonance imaging (MRI) techniques have provided invaluable insights into how language is represented and processed in the brain and how it can be disrupted by damage to, or dysfunction of, various parts of the brain. Current functional MRI (fMRI) approaches have also allowed researchers to purposefully investigate how individuals recover language after stroke. This paper presents recommendations for quantification of brain lesions derived from discussions among international researchers at the Neuroimaging in Aphasia Treatment Research Workshop held at Northwestern University (Evanston, Illinois, USA). Methods for detailing and characterizing the brain damage that can influence results of fMRI studies in chronic aphasic stroke patients are discussed. Moreover, we aimed to provide the reader with a set of general practical guidelines and references to facilitate choosing adequate structural imaging strategies that facilitate fMRI studies in aphasia treatment research.

Outcome after systemic thrombolysis is predicted by age and stroke severity: an open label experience with recombinant tissue plasminogen activator and tirofiban

Stroke patients can recover upon intravenous thrombolysis but remain impaired in lacking recanalization. We sought to investigate the clinical effect of systemic thrombolysis with an intravenous bolus of 20 mg recombinant tissue plasminogen activator (rtPA) and an infusion of body-weight adjusted tirofiban for 48 hours in acute stroke. This prospective, open label study, included 192 patients (68±13 years, 50% males) treated between 1 January 2005 and 31 December 2007. The neurological deficit was assessed with the National Institutes of Health stroke scale (NIHSS). Follow-up was performed using a telephone interview of modified Rankin Scale (mRS) and Barthel index. The site of cerebral artery occlusion was determined by computed tomography or magnetic resonance angiography. Data were analyzed by descriptive statistics and multiple regression analyses. Eighty-one percent of the patients had an infarct in the middle cerebral artery (MCA) territory and were severely affected with a median NIHSS of 10. During treatment on the Stroke Unit the patients improved (P<0.0001) except for patients who deceased due to malignant infarction (n=10) or cerebral haemorrhage (n=6); 18 percent deceased within 100 days which was predicted by older age (76 + 10 years, P<0.05) and more severe affection on admission (P<0.0001). Also, these patients more frequently had atrial fibrillation (P<0.03) than the surviving patients. The surviving patients had more frequently distal MCA occlusions and improved further (P<0.0001). At follow-up 48% of the patients had a mRS of 0 and 1. Similarly to intravenous thrombolysis with body-weight adjusted rtPA, poor prognosis was predicted by higher age, more severe neurological deficit at stroke admission, and a proximal MCA occlusion. Half of the surviving patients improved to no or minimal impairment.

Towards understanding the cause of stroke in young adults utilising a new stroke classification system (A-S-C-O)

BACKGROUND

Stroke in younger people is relatively common and frequently unexplained. While understanding of the causes of young stroke has improved, there remains uncertainty over the role of low-risk lesions such as a patent foramen ovale (PFO). The TOAST criteria are often used to describe stroke aetiology, but in younger people in whom PFOs are frequent, there is a very high proportion of cases attributed to cardiac embolism. The impact of using the newer A-S-C-O criteria on stroke aetiology was investigated.

METHODS

Consecutive patients with ischaemic stroke were investigated and categorised by the TOAST and ASCO1 criteria. Stroke aetiology was presented and compared by the different classification systems.

RESULTS

Of the 106 ischaemic stroke cases, by TOAST 6% were 'large artery atheroma', 11% 'small vessel occlusion', 28% 'cardioembolic', 22% 'other determined cause' and 33% 'undetermined cause'. The vascular territory and associated causes are presented. With the ASCO1 criteria, there were more cases of unclassified stroke (51.9 vs. 34.0%; p < 0.001) and fewer cases of cardiac embolism. Kappa ranged from 0.5 for 'undetermined aetiology' to 1.0 for both 'large artery atheroma' and 'other determined aetiology'. Younger cases (<45 years) were less likely to be either 'large artery atheroma' or 'small vessel occlusion'.

CONCLUSION

Using the ASCO criteria, more patients fall into the undetermined group which more accurately reflects our current uncertainty regarding the pathogenic relevance of PFOs in this age group.

Sex differences in antiplatelet response in ischemic stroke

Sex differences exist in the occurrence, treatment and outcome of ischemic stroke. Compared with men, women have more stroke events and are less likely to fully recover from a stroke. Given the rapidly aging population, stroke incidence and mortality among women are projected to substantially rise by 2050. This has important public health consequences. Mitigating the burden of stroke among women will require a fundamental understanding of sex differences and sex-specific issues including cerebrovascular disease pathophysiology, treatment and outcome. An aspect of stroke treatment receiving increasing but insufficient attention involves possible interactions between estrogen levels, antiplatelet drugs and stroke outcome. Emerging evidence suggests that antiplatelet therapy may provide primary stroke protection but not primary myocardial infarction prevention in women, while the opposite may be true among men. Understanding sex-specific issues related to women who experience stroke is critical to clinicians who treat women with antiplatelet medications as part of a secondary stroke prevention regimen; however, the ideal antiplatelet medication, and dose, in women requires further research. In this article we present a conceptual framework for sex differences in antiplatelet treatment response in ischemic stroke, thrombus formation and the mediating role of estrogen, sex differences in antiplatelet treatment response in clinical trials, and sex differences in antiplatelet treatment use in ischemic stroke.

Treatment Issues in Spontaneous Cervicocephalic Artery Dissections

The management of cervicocephalic arterial dissections raises many unsolved issues such as: how to best acutely treat patients who present with ischemic stroke or occasionally with sub-arachnoid hemorrhage? How to best prevent ischemic stroke in patients who present with purely local signs such as headache, painful Horner Syndrome or neck pain? How long and how should patients be treated after cervicocephalic arterial dissections? Can patients resume their sports activities and when? The consensus is that, given the well-established initial thromboembolic risk, an urgent antithrombotic treatment is required in patients with a recent nonhemorrhagic cervicocephalic arterial dissection, but the type of antithrombotic treatment – anticoagulants or aspirin – as well as the indication for a local arterial treatment such as angioplasty/stenting remain debated. Evidence from a randomized clinical trial would be welcome but such a trial raises major issues of methodology, feasibility and funding. Meanwhile, cervicocephalic arterial dissection remains a situation when a bedside clinician should use, on a case-by-case basis, best clinical judgment and adopt a stepped care approach in the minority of patients who deteriorate despite initial treatment.

Optimizing the management of elderly colorectal surgery patients

With the ever increasing number of geriatric surgical patients, there is a need to develop efficient processes that address all of the potential issues faced by patients during the perioperative period. This article explores the physiological changes in elderly surgical patients and the outcomes achieved after major abdominal surgery. Perioperative management strategies for elderly surgical patients in line with the practices of the Geriatric Surgical Team of Alexandra Health, Singapore, are also presented. A coordinated transdisciplinary approach best tackles the complexities encountered in these patients.

Laparoscopic colorectal surgery in elderly patients: a case-control study of 15 years of experience

INTRODUCTION

The aim of this study was to review the impact of age (≥75 years) on the short-term outcomes of laparoscopic colorectal surgery.

METHODS

Three hundred seventy-nine patients under 70 years of age and 91 patients 75 years and older were analyzed. Quantification of comorbidities was performed using the Charlson Weighted Comorbidity Index. Outcome measures were postoperative complications and 30-day mortality.

RESULTS

There was no difference in the occurrence of postoperative complications between the younger and older patients. Bivariate analysis revealed that patient age was not a risk factor of major complications (odds ratio = 1.2; 95% confidence interval, .6-2.3). Although bivariate analysis revealed that older age had a statistically significant odds ratio for 30-day mortality (odds ratio = 12.8; 95% confidence interval, 1.3-125.4), multivariate analysis revealed that it was a weighted comorbidity index score of 5 or more (P = .02) and long operative time (P = .01) that were independent predictors of 30-day mortality and not age per se.

CONCLUSIONS

Age is not an independent predictor of morbidity and mortality in laparoscopic colorectal cancer surgery.

Predicting functional outcomes in patients suffering from ischaemic stroke using initial admission variables and physiological data: a comparison between tree model and multivariate regression analysis

PURPOSE

This study was aimed to compare the application of a tree model and regression approach for developing data-driven models that identified frisk factors related to functional outcomes among ischaemic stroke patients.

METHODS

Data were derived from 271 hospitalised patients with a first-ever ischaemic stroke. The Barthel Index (BI) and Modified Rankin Scale (MRS) were used to assess the functional outcomes. The stroke severity at admission and related information from 2006 to December 2007 were extracted retrospectively from a chart review.

RESULTS

In the regression approach, including age, the National Institutes of Health Stroke Scale (NIHSS) score and glucose level were the most significant predictors affecting both the BI and MRS. After applying the tree model, different tree structures were found. For the BI score, the NIHSS score interact with glucose, age and systolic blood pressure to form the tree structure. By contrast, the NIHSS score mainly interact with patients' age to form the tree model for MRS.

CONCLUSION

Both models have their pros and cons. The tree model otherwise provides risk interactions, and can effectively discriminate the risk groups for different functional outcomes. Applying both models to specific situations will provide a different angle for functional assessment and intervention in stroke rehabilitation.

Predicting language outcome and recovery after stroke: the PLORAS system

The ability to comprehend and produce speech after stroke depends on whether the areas of the brain that support language have been damaged. Here, we review two different ways to predict language outcome after stroke. The first depends on understanding the neural circuits that support language. This model-based approach is a challenging endeavor because language is a complex cognitive function that involves the interaction of many different brain areas. The second approach, by contrast, does not require an understanding of why a lesion impairs language; instead, predictions are made on the basis of the recovery of previous patients with the same lesion. This approach requires a database that records the speech and language capabilities of a large population of patients who have, collectively, incurred a comprehensive range of focal brain lesions. In addition, a system is required that converts an MRI scan from a new patient into a three-dimensional description of the lesion and compares this lesion against all others on the database. The outputs of this system are the longitudinal language outcomes of corresponding patients in the database. This approach will provide the patient with a range of probable recovery patterns over a variety of language measures.

What is a minor stroke?

BACKGROUND AND PURPOSE

The term "minor stroke" is often used; however a consensus definition is lacking. We explored the relationship of 6 "minor stroke" definitions and outcome and tested their validity in subgroups of patients.

METHODS

A total of 760 consecutive patients with acute ischemic strokes were classified according to the following definitions: A, score < or = 1 on every National Institutes of Health Stroke Scale (NIHSS) item and normal consciousness; B, lacunar-like syndrome; C, motor deficits with or without sensory deficits; D, NIHSS < or = 9 excluding those with aphasia, neglect, or decreased consciousness; E, NIHSS < or = 9; and F, NIHSS < or = 3. Short-term outcome was considered favorable when patients were discharged home, and favorable medium-term outcome was defined as a modified Rankin Scale score of < or = 2 at 3 months. The following subgroup analyses were performed by definition: sex, age, anterior versus posterior and right versus left hemispheric stroke, and early (0 to 6 hours) versus late admission (6 to 24 hours) to the hospital.

RESULTS

Short-term and medium-term outcomes were most favorable in patients with definition A (74% and 90%, respectively) and F (71% and 90%, respectively). Patients with definition C and anterior circulation strokes were more likely to be discharged home than patients with posterior circulation strokes (P=0.021). The medium-term outcome of older patients with definition E was less favorable compared with the outcome of younger ones (P=0.001), whereas patients with definition A, D, and F did not show different outcomes in any subgroup.

CONCLUSIONS

Patients fulfilling definition A and F had best short-term and medium-term outcomes. They would be best suited to the definition of "minor stroke."