Risk factors and outcome of subtypes of ischemic stroke. Data from a multicenter multinational hospital-based registry. The European Community Stroke Project

Analyzing post-endovascular treatment stroke prognosis with transcranial Doppler and quantitative electroencephalography

OBJECTIVE

Despite successful recanalization following acute ischemic stroke, patients may have a poor prognosis. We investigated whether transcranial Doppler combined with quantitative electroencephalography can identify patients with a poor prognosis at an early stage.

METHODS

Prospectively recruited patients with successful recanalization after endovascular treatment for acute ischemic stroke were assessed for prognosis at 90 days using the modified Rankin Scale. Clinical information and National Institute of Health Stroke Scale scores were recorded. Transcranial Doppler combined with quantitative electroencephalography was used to evaluate brain function.

RESULTS

Of the 37 patients (63.5 ± 11.7 years) studied, 18 had a poor prognosis at 90 days (modified Rankin Scale >3). Multivariable analysis revealed that transcranial Doppler indicators of the pulsatility index of the unaffected side, quantitative electroencephalography indicators of the pairwise-derived Brain Symmetry Index, and National Institute of Health Stroke Scale score were independent prognostic indicators. Modeling indicated that combining these independent predictors yielded superior accuracy and net clinical benefit to any single variable. With the final predictive model presented as a nomogram, internal validation by bootstrap resampling showed good discrimination with a concordance index of 0.961. The calibration curve displayed good agreement of predicted and actual probabilities.

INTERPRETATION

The nomogram prediction model combining transcranial Doppler with quantitative electroencephalography and National Institute of Health Stroke Scale scores can provide guidance for individualized risk prediction in patients with acute ischemic stroke after revascularization.

Risk Factors and Stroke Subtyping in Young Adults: A Study From a Tertiary Care Hospital in South India

OBJECTIVES

This study aimed to determine the risk factors and stroke subtypes for young ischemic stroke patients and their outcomes at the time of discharge.

METHODS

This is a retrospective cross-sectional study of ischemic stroke patients (n = 264) between the age groups of 18 and 45. The study population was divided into two broad age groups: 18 to 35 years and 36 to 45 years; and compared based on demographics, risk factors, the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and outcomes. The outcomes were compared based on the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (MRS) systems at the time of admission and discharge.

RESULTS

The mean age of patients was 37.84±6.19 years. The male-to-female ratio was 2.5:1. The most common vascular risk factors identified were diabetes (29.16%), hypertension (49.62%), dyslipidaemia (DLP, 44.4%), and smoking (10.9%). The most common TOAST subtype was large vessel disease (38.63%), followed by the undetermined category (35.6%). The elderly group showed a high proportion of strokes secondary to small vessel disease (14.13%; p = 0.03), while cardioembolic strokes were common in the female subgroup (p = 0.05). The majority of strokes were in the anterior circulation (66.6%) as compared to the posterior (25.75%), and nearly 50% of the patients had intracranial disease. Overall, there was a favourable MRS outcome at discharge.

CONCLUSION

Conventional vascular risk factors are equally prevalent, even among young stroke patients. The benchmark for young stroke age is showing a downward shift as more stroke patients above the age of 35 are showing similar risk factor trends as those of their older counterparts. The majority of stroke burden still falls under the undermined category, which requires aggressive risk factor identification and management.

Predictors of congruency between clinical and radiographic Oxfordshire Community Stroke Project Classification subtypes

BACKGROUND

The Oxfordshire Community Stroke Project (OCSP) classification has been widely used to assess ischemic stroke patients based on clinical characteristics alone. However, the correlation between the clinical presentation evaluated using OCSP and imaging findings is yet to be determined. Our study aimed to describe the baseline characteristics of the OCSP subtypes of patients admitted with ischemic stroke and evaluate the predictors of the relationship between clinical and neuroimaging findings.

METHODS

Patients with a confirmed diagnosis of ischemic stroke admitted to a comprehensive stroke center in Brazil between February 2015 and October 2017 were eligible for the study. All participants underwent computed tomography (CT) at admission and follow-up neuroimaging within seven days, per the institutional protocol. Trained staff classified patients according to the OCSP at hospital admission. The radiographic OCSP classification was retrospectively assessed based on the last follow-up neuroimaging by investigators unaware of the clinical classification.

RESULTS

The overall agreement rates ranged from 65.5% to 88.7%. Lower NIHSS scores, absent hyperdense MCA sign, higher ASPECTS, and absent brainstem symptoms were related to a higher risk of misclassification. Treatment with intravenous tPA was associated with reclassification in patients with total anterior circulation syndrome. For predicting radiographic posterior circulation involvement, vertigo (OR 2.9, 95% CI 1.7-5.1, p < 0.001) and brainstem symptoms (OR 35, 95% CI 20.5-60.2, p < 0.001) were directly associated with correct classification, but motor and higher cerebral function were not correlated.

CONCLUSION

The clinical OCSP classification presented good congruency rates with the neuroimaging findings. However, patients with lacunar syndromes are often misclassified when radiological criteria are considered.

Clinical and Imaging Phenotypes and Outcomes in a Costa Rican Cohort of Acute Ischemic Stroke Survivors: A Retrospective Study

BACKGROUND

We characterized clinical and imaging phenotypes and their association with clinical outcomes in acute ischemic stroke (AIS) survivors in the understudied region of Costa Rica.

METHODS

We conducted a retrospective cohort study in AIS patients treated at a tertiary stroke center in Costa Rica from 2011-2015. Participants underwent detailed phenotyping for cardiovascular risk factors and stroke etiology. We assessed the association of ischemic brain lesion features and clinical outcomes using the Oxfordshire Community Stroke Project (OCSP) classification.

RESULTS

We included 684 AIS survivors (60.2% males, aged 68.1 ± 13.6 years, mean ± SD). While the cardiovascular risk profiles and mortality rates of our patients were similar to populations in European and North American countries, only 20.2% of patients with atrial fibrillation (AF) received anticoagulation. On multivariable analysis, patients with total anterior circulation infarct (TACI) displayed an increased risk of complications (OR: 4.2; 95% CI: 2.2-7.8; p < 0.001), higher mortality (OR: 6.9; 95% CI: 2.9-16.1; p < 0.001) and lower chance of functional independence at discharge (OR: 8.9; 95% CI: 4.1-19; p < 0.001) compared to non-TACI. The comorbidity of bronchopneumonia increased the probability of death by 14.5 times.

CONCLUSIONS

Our observations in a Costa Rican cohort of AIS survivors might help improve local measures for preventing and managing AIS.

Ischemic Stroke Subtypes: Socio-demographic Factors, Risk Factors, and Outcomes in Southern Sri Lanka

Background

Stroke is a heterogeneous, catastrophic disease. A comprehensive clinical analysis of ischemic stroke (IS) risk factors and outcomes is crucial for optimum management in resource-poor settings.

Methods

A prospective cross-sectional study of acute cerebrovascular disease (ACVD) involving 592 patients was conducted in a tertiary care center in Sri Lanka from November 2018 to May 2019. We aimed to describe the ACVD subtypes and the relationship of IS subtypes and subtype-categories (as defined by the Oxfordshire Community Stroke Project clinical classification) with risk factors, severity, and outcome.

Results

The majority (63.3%) had IS. Partial anterior circulation syndromes (PACS), total anterior circulation syndrome (TACS), posterior circulation syndromes (POCS), and lacunar syndromes (LACS) accounted for 102 (29.7%), 58 (16.9%), 88 (25.7%) and 95 (27.7%) of the cases, respectively. The most common PACS sub-category was higher-cerebral-dysfunction-with-homonymous-hemianopia (HCD+HH,39 cases;38.2%). Cerebellar-signs-without-long-tract-signs (CS-LTS) sub-category constituted the highest among POCS (47 cases; 53.4%). The leading sub-category within LACS was pure-motor (PM) strokes (43 cases; 45.3%).Patients aged ≥50 years (adjusted-OR [AOR]2.439; 95%CI,1.163-5.116;P=.018), IHD(AOR 2.520; 95%CI,1.347-4.713; P=.004) and BMI>23kg/m²(AOR 2.607; 95% CI,1.420-4.784; P=.002) were 2.5 times more likely to associate with TACS. Patients with a history of TIA (AOR 1.910; 95%CI,1.036-3.524; P=.038) and arrhythmias (AOR 5.933; 95%CI,3.294-10.684; P<.001) were 1.9 and 5.9 times more likely to be associated with POCS respectively. Those with hypertension were 2.3 times more likely to associate with LACS (AOR 2.233; 95%CI,1.270-3.926; P=.005).NIHSS(P<.001), mRS on admission (P=.001) and in 3 months (P<.001), deaths during hospital stay (P=.003) and within 28 days (P<.001) had a stronger relationship with individual stroke subtypes.

Conclusion

The comparative risk of different IS subtypes depends on different risk factors. The findings of this study demonstrate that sub-categories within each stroke subtype may behave independently with regard to risk factors and outcomes, thus warranting the need for individual assessment.

Cohort study on the prognosis of acute cerebral infarction in different circulatory systems at 1-year follow-up

Background

To evaluate the prognosis of acute cerebral infarction at 1-year follow-up in different circulation infarctions.

Methods

Clinical data of 858 consecutive patients with acute cerebral infarction were collected. Of the 858 cases, 21 (2.45%) were lost to follow-up and 837 completed follow-up and thus were enrolled in this study. At 1-year follow-up, death or moderate-to-severe dysfunction (modified Rankin Scale (mRS) ≥ 3 points) was regarded as the poor prognostic endpoint. Univariate analysis and multivariate logistic stepwise regression analysis were performed to assess the prognosis. The prediction probability of indicators was obtained for the multivariate model, and the receiver operating characteristic curve was delineated to calculate the area under the curve (AUC) to predict the fitness of the model.

Results

The older the age, the greater the probability of a poor prognosis. Patients with previous diabetes and cerebral infarction had a poor prognosis. The higher the National Institutes of Health Stroke Scale and mRS scores and the lower the Barthel index at admission, the worse the prognosis of the patients. The longer the hospital stay, the worse the prognosis of the patients. The prognosis of different circulation infarctions was different. The AUC of the multivariate model was AUC = 0.893, and the 95% confidence interval was 0.870–0.913, indicating a good fit. The prognosis of anterior circulation infarction (ACI) was worse than that of posterior circulation infarction (PCI) (P < 0.05). The prognosis of patients with ACI and PCI was not significantly different from that of patients with ACI or PCI alone (P > 0.05).

Conclusions

Diabetes, the Barthel index at admission and previous cerebral infarction are poor prognostic factors of acute cerebral infarction. The prognosis of ACI is worse than that of PCI. Different factors affect the prognosis of different circulatory system infarctions.

Prevalence and characteristics of atherosclerotic plaque: Left compared with right arteries and anterior compared with posterior circulation stroke

PURPOSE

To evaluate atherosclerotic plaque prevalence and characteristics between left and right cervicocephalic arteries and between anterior and posterior circulation stroke (ACS and PCS).

METHODS

This retrospective study included 284 patients with acute ischemic stroke (199 ACS and 85 PCS) involving large-artery atherosclerosis or small-artery occlusion. We assessed atherosclerotic plaque prevalence and characteristics (plaque type, plaque surface morphology, plaque distribution, location of calcified nodules and plaque thickness) in each segment and their comparisons between left and right arteries and between ACS and PCS.

RESULTS

The left subclavian artery (L-SA), common carotid artery (L-CCA) and intracranial vertebral artery (L-IVA) had significantly higher prevalence of atherosclerotic plaque than the right (R) corresponding arteries (70.1% versus 59.5%, P = 0.008), (48.1% versus 28.9%, P < 0.001), (23.9% versus 16%, P = 0.018), respectively. L-SA had a higher prevalence of mixed plaque (non-calcified > calcified) (19.6% versus 16.4%) and noncalcified plaque (51.9% versus 31.7%), and a lower prevalence of calcified plaque (8.9% versus 23.3%) and mixed plaque (calcified > non-calcified) (19.6% versus 28.6%) than R-SA, P < 0.001. The distribution of plaque type in the SA and extracranial vertebral artery (EVA) were significantly different between ACS and PCS. The soft plaque thickness of SA in PCS was significantly greater than that in ACS (3.85 ± 1.27 versus 3.51 ± 1.04, P = 0.032).

CONCLUSIONS

Atherosclerotic plaque prevalence and characteristics vary in different segments, sides and between ACS and PCS. These differences should be noted during plaque diagnosis.

Comparison of Ischemic and Hemorrhagic Stroke in the Medical Ward of Dessie Referral Hospital, Northeast Ethiopia: A Retrospective Study

Background

Distinguishing the category of stroke plays a vital role in planning patient care. Simple clinical findings help distinguish the type of stroke. However, there is a need for diagnostic imaging. In Ethiopia, stroke is the most common neurological condition in patients admitted to hospitals. Yet, there are limited data on comparisons of stroke subtypes. Thus, this study was designed to determine the prevalence of stroke and to compare ischemic and hemorrhagic strokes.

Methods

A retrospective cross-sectional study design was employed. Medical records containing complete information and confirmed diagnosis using imaging techniques were included. The data were entered into SPSS version 24.0 for analysis. Results with a P value of <0.05 were considered statistically significant.

Results

From a total of 312 stroke patients, 204 (65.4%) patients were admitted due to ischemic stroke. More females, 59 (18.9%), were admitted for hemorrhagic stroke than males. In both ischemic, 175 (56.1%) and hemorrhagic, 91 (29.2%) stroke cases, most of the patients were 45 years and above. Middle cerebral artery territory was the most common site of arterial territory infarctions in ischemic stroke, 158 (50.7%). Middle cerebral artery territory also was the most common site of hematoma in hemorrhagic stroke, 91 (29.2%). Infarctions in more than one lobe of the cerebrum (16.4%) and intracerebral hemorrhage in multiple areas of the cerebrum (7.4%) were observed in ischemic as well as hemorrhagic stroke cases. Most of the ischemic, 124 (39.8%), and hemorrhagic, 39 (12.5%), stroke patients presented loss of sensation and weakness of body parts. Hypertension was observed in 124 (39.8%) ischemic and 73 (23.4%) hemorrhagic stroke patients. The mortality rate of ischemic stroke, 47 (15.3%), was two times higher than hemorrhagic stroke, 20 (6.5%). Hypertension was the most common predictor of death in both ischemic and hemorrhagic stroke cases.

Conclusions

Ischemic stroke is a common type of stroke in the medical ward of the study hospital. More females were affected by hemorrhagic stroke than males. Middle cerebral artery territory was the most affected area of the brain in both ischemic and hemorrhagic strokes. Most ischemic and hemorrhagic stroke patients were admitted due to loss of sensation and weakness of body parts. Hypertension was the most common risk factor of stroke as well as a predictor of stroke-related deaths. Identification of the stroke subtypes may be important in the management of stroke. Thus, health professionals, government officials, community leaders, and the population at large could be involved in creating awareness about antecedent risk factors and clinical presentations of stroke subtypes.

The association between telomere length and ischemic stroke risk and phenotype

The chronological age of a person is a key determinant of etiology and prognosis in the setting of ischemic stroke. Telomere length, an indicator of biological aging, progressively shortens with every cell cycle. Herein, we determined telomere length from peripheral blood leukocytes by Southern blot analyses in a prospective cohort of ischemic stroke patients (n = 163) and equal number of non-stroke controls and evaluated its association with various ischemic stroke features including etiology, severity, and outcome. A shorter telomere length (i.e. lowest quartile; ≤ 5.5 kb) was significantly associated with ischemic stroke (OR 2.95, 95% CI 1.70–5.13). This significant relationship persisted for all stroke etiologies, except for other rare causes of stroke. No significant association was present between admission lesion volume and telomere length; however, patients with shorter telomeres had higher admission National Institutes of Health Stroke Scale scores when adjusted for chronological age, risk factors, etiology, and infarct volume (p = 0.046). On the other hand, chronological age, but not telomere length, was associated with unfavorable outcome (modified Rankin scale > 2) and mortality at 90 days follow-up. The association between shorter telomere length and more severe clinical phenotype at the time of admission, might reflect reduced resilience of cerebral tissue to ischemia as part of biological aging.

Impact of revascularization therapies on outcome of posterior circulation ischemic stroke: The Indo-US stroke project

INTRODUCTION

Posterior circulation strokes (PCS) have been less extensively studied than anterior circulation strokes (ACS), especially regarding revascularization therapies. We analyzed the differences in baseline stroke characteristics, revascularization therapy and 3-month outcomes between PCS and ACS in a large prospective multicentre Indian stroke registry.

METHODS

Patients with acute ischemic stroke recruited in the Indo-US collaborative stroke project from January 2012 to August 2014 were classified into PCS and ACS based on imaging-confirmed infarct location. Demographics, stroke severity, risk factors, and mechanisms were compared. We further compared these parameters in the subgroups who received revascularization therapies (RT) and no revascularization therapies (NRT). The primary outcome was 3-month modified Rankin scale (mRS).

RESULTS

Of 1889 patients (1270 males), 1478 (78.2%) had ACS and 411 (21.8%) PCS. The median NIHSS was lower in PCS (7 vs 11, p < 0.001). Diabetes mellitus and hypertension were more common in PCS and rheumatic heart disease in ACS. Small artery occlusion was higher in PCS (23.8% vs 12.9%, p < 0.001). Only 28 (6.8%) PCS received RT compared to 213 (14.4%) ACS. At 90 days, a good functional outcome (mRS 0-2) was more common in PCS (56.4% vs 45.9%, p < 0.001) in NRT group, while no significant difference was noted in RT group. Stroke territory was not an independent predictor of 3-month outcome in regression analysis. In-hospital mortality was not different between the groups.

CONCLUSIONS

The 3-month functional outcome and in-hospital mortality were not different between ACS and PCS. Compared to ACS, PCS received revascularization therapies less often.

SARS-CoV-2 and Stroke Characteristics: A Report From the Multinational COVID-19 Stroke Study Group

Supplemental Digital Content is available in the text.

Background and Purpose:

Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale.

Methods:

We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes.

Results:

Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were <55 years of age, and 105 (24.4%) patients had no identifiable vascular risk factors. Among acute ischemic stroke patients, 44.5% (126 of 283 patients) had large vessel occlusion; 10% had small artery occlusion according to the TOAST criteria. We observed a lower median National Institutes of Health Stroke Scale (8 [3–17] versus 11 [5–17]; P=0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; P<0.001) in countries with middle-to-high health expenditure when compared with countries with lower health expenditure. Among 380 patients who had known interval onset of the SARS-CoV-2 and stroke, 144 (37.8%) were asymptomatic at the time of admission for SARS-CoV-2 infection.

Conclusions:

We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.

Risk factors among stroke subtypes and its impact on the clinical outcome of patients of Northern Portugal under previous aspirin therapy

BACKGROUND

In Western European countries, acute ischemic stroke (AIS) remains the third leading cause of death. Among the risk factors for cerebrovascular disease, some have more influence than others in certain stroke subtypes. The aim of this study was to evaluate the impact of risk factors among Stroke Subtypes on the clinical outcome of Portuguese patients under previous aspirin therapy.

MATERIALS AND METHODS

We studied a cohort of 371 patients diagnosed with AIS and a clinical follow-up protocol was set up.The patients were admitted in a Department of Internal Medicine of a major hospital. Standardized data assessment and stroke subtype classification (Oxfordshire Community Stroke Project) were used.

RESULTS

Arterial hypertension (80.4 %), overweight (72.6 %) and dyslipidemia (62.0 %) were the most prevalent risk factors with no statistical differences among the group's subtypes. Current smoking was more prevalent in POCI(62.9 %) with differences among subtypes (p = 0.002). Atrial fibrillation was more commonly reported in TACI (39.3 %) and less common in POCI (8.1 %) (p < 0.001).Comparing TACI vs Non TACI Stroke Subtypes demonstrated major differences in cumulative survival,among the cases with no previous aspirin treatment, after 3 years (51.9 % vs 88.8 %).The increased risk of mortality at 12 months is consistently observed for the presence of a previous atrial fibrillation (OR 3.01 95 %CI 1.69-5.39), TACI subtype (OR 10.4 95 %CI 4.83-22.6) and NIHSS over 10 (OR 9.33 95 % CI 4,49-19.4). When we analyze the impact of previous aspirin treatment in the risk for a new stroke event, it seems to have a protective effect in a time frame of 12 months, but this protection is lost extending at 24 months (p = 0.094 vs p = 0.005).

DISCUSSION

Our results indicate that smoking, atrial fibrillation and age have different relevance in their distribution among ischemic stroke subtypes at the time of diagnosis. Concerning the influence of the main stroke risk factors on the clinical outcome, our results present a strong influence of atrial fibrillation and of age. Severity of disease at diagnosis, represented by TACI subtype is clearly associated to decreased survival among patients with no record of previous aspirin therapy. Our results reinforce the relevance cohort studies of different populations, to achieve a more comprehensive knowledge of the impact of risk factors on stroke subtypes and on its clinical outcome.

Examining Outcomes following Thrombolysis in An Increasingly Older and Dependent Stroke Population

Background

Thrombolysis for acute ischaemic stroke (AIS) patients aged ≥80 years is evidence based, although its use in previously dependent patients is controversial.

Methods

Data from 831 thrombolysed AIS patients in our centre from 2009–2017 were used to compare demographic trends and outcomes (haemorrhage, mortality, three-month independence) in patients aged <80 and ≥80 years and with prior dependency. Comparison with UK and world registry data regarding age and pre-stroke dependency was made.

Results

The percentage of treated patients aged ≥80 years increased year-on-year, doubling from 25% to 50% (p<0.01), with increasing average age and pre-stroke dependency in world centres. Patients ≥80 years had higher (p<0.001) stroke severity, symptomatic intracerebral haemorrhage (5% vs. 1.5%), mortality (35% vs. 13%) and lower three month independent survival (24% vs. 60%). Patients with pre-stroke dependency had especially higher three month mortality (57–71%, OR 3.75 [95% CI 1.97–7.15]) in both age groups.

Conclusion

Patients aged ≥80 years and with dependency increasingly receive thrombolysis. Given poorer outcomes thrombolysis trials are needed in pre-stroke dependent patients.

Cerebral Thrombolysis in Rural Residents Aged ≥ 80

Purpose

The proportion of older people in Poland is higher in rural areas than in urban areas. Thus, we aimed to evaluate treatment rate and factors associated with outcome and safety of intravenous thrombolysis (IVT) in rural residents aged ≥80 years admitted to primary stroke centers.

Patients and Methods

This study was a retrospective, observational cohort study of 873 patients treated with recombinant tissue plasminogen activator (rt-PA) in primary stroke centers between February 1, 2009 and December 31, 2017. Among them were 527 rural residents and 231 (26.5%) were ≥80 years of age. The analyses between rural and urban patients aged ≥80 and between rural patients aged <80 and aged ≥80 were performed.

Results

The proportion of patients aged ≥80 treated with rt-PA was comparable in rural and urban residents (27.9% vs 24.3% p = 0.24). Rural patients aged ≥80 were also characterized by lower incidence of cardiovascular risk factors and better patients’ conditions on admission to hospital. Symptomatic intracerebral hemorrhage rate among ≥80-year-old stroke patients was lower in those living in rural areas than in those living in urban areas (5.4% vs 14.3%, p = 0.02); there were no differences regarding mortality and 3-month functional outcome between both populations. The older group of rural patients was characterized by a higher 3-month mortality (28.5% vs 12.6%, p < 0.001) and lower functional independence rate (34.0% vs 50.5%, p < 0.001) than rural younger patients. Antiplatelet (OR 2.43, 95% CI 1.04–5.66, p = 0.04) and anticoagulant therapy before stroke (OR 3.64, 95% CI 1.21–10.99, p = 0.022), early ischemic changes in baseline computerized tomograprpahy (OR 2.65, 95% CI 1.03–6.82, p = 0.043) were associated with unfavorable outcome; and higher National Institute of Health Stroke Scale score on admission (OR 1.01, 95% CI 1.01–1.20, p = 0.039), higher baseline count of white blood cells (OR 1.33, 95% CI 1.10–0.62, p = 0.003) were associated with mortality in rural patients over 80.

Conclusion

We suggest that rural patients aged ≥80 may be safely treated with IVT in routine practice. However, lower efficacy and a higher mortality must be considered in former use of Vitamin K antagonist and antiplatelet or high white blood cells count.

Permanent Bilateral Carotid Filters for Stroke Prevention in Atrial Fibrillation

Purpose of Review

A novel permanent carotid filter device for percutaneous implantation was developed for the purpose of stroke prevention. In this review, we cover rationale, existing preclinical and clinical data, and potential future directions for research using such a device.

Recent Findings

The Vine™ filter was assessed for safety in sheep and in 2 observational human studies, the completed CAPTURE 1 (n = 25) and the ongoing CAPTURE 2 (planned n = 100). CAPTURE 1 has shown high procedural and long-term implant safety. A control group was not available for comparison.

Summary

A mechanical filter for permanent stroke prevention can be implanted bilaterally in the common carotid artery safely and efficiently. A randomized trial is planned for 2021 (n = 3500, INTERCEPT) to demonstrate superiority of a filter + anticoagulation strategy over anticoagulation alone in patients at high risk for ischemic stroke.

Timing of initiation of oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation comparing posterior and anterior circulation strokes

Introduction

The aim of this study in patients with acute posterior ischaemic stroke (PS) and atrial fibrillation (AF) was to evaluate (1) the risks of recurrent ischaemic event and severe bleeding and (2) these risks in relation with oral anticoagulant therapy (OAT) and its timing.

Materials and Methods

Patients with PS were prospectively included; the outcome events of these patients were compared with those of patients with anterior stroke (AS) which were taken from previous registries. The primary outcome was the composite of stroke recurrence, transient ischaemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding occurring within 90 days from acute stroke.

Results

A total of 2470 patients were available for the analysis: 473 (19.1%) with PS and 1997 (80.9%) with AS. Over 90 days, 213 (8.6%) primary outcome events were recorded: 175 (8.7%) in patients with AS and 38 (8.0%) in those with PS. In patients who initiated OAT within 2 days, the primary outcome occurred in 5 out of 95 patients (5.3%) with PS compared to 21 out of 373 patients (4.3%) with AS (OR 1.07; 95% CI 0.39-2.94). In patients who initiated OAT between days 3 and 7, the primary outcome occurred in 3 out of 103 patients (2.9%) with PS compared to 26 out of 490 patients (5.3%) with AS (OR 0.54; 95% CI 0.16-1.80).

Discussion

our findings suggest that, when deciding the time to initiate oral anticoagulation, the location of stroke, either anterior or posterior, does not predict the risk of outcome events.

Conclusions

Patients with PS or AS and AF appear to have similar risks of ischaemic or haemorrhagic events at 90 days with no difference concerning the timing of initiation of OAT.

Effectiveness of Stroke Rehabilitation Compared between Intensive and Nonintensive Rehabilitation Protocol: A Multicenter Study

BACKGROUND AND AIM

Stroke is one of the leading causes of death, physical disability, and economic burden. Nowadays, various types of rehabilitation are available. Rehabilitation centers in Thailand provide services in different ways, including starting time, duration, and frequency of each therapy. In addition, many rehabilitation wards have a standing policy to reduce length of stay (LOS) due to economic considerations. This study aimed to compare the effectiveness and efficiency between intensive and nonintensive rehabilitation protocol for stroke patients.

METHODS

This prospective, multicenter cohort study was conducted among stroke patients who admitted to rehabilitation wards at 14 centers. All participants received either intensive or non-intensive rehabilitation program. Barthel Index (BI) at admission (BIad), BI at discharge (BIdc), and LOS were recorded. The effectiveness was difference in BIdc and BIad score (ΔBI), and the efficiency was ΔBI divided by LOS (ΔBI/LOS).

RESULTS

Seven hundred and eighty stroke patients were included. Mean age was 61.9 ± 13.3 years, and 59.7% were male. The majority of patients (79.5%) were admitted for intensive rehabilitation. Effectiveness and efficiency were significantly higher in the intensive group than in the nonintensive group (4.5 ± 3.4 versus 2.6 ± 3.2 and .24 ± .30 versus .18 ± .33, respectively). LOS, intensive rehabilitation, and quality of life were significantly positively correlated with effectiveness; whereas, age, onset to admission interval (OAI), and BIad were significantly negatively correlated with the effectiveness of stroke rehabilitation.

CONCLUSIONS

Stroke patients admitted for intensive rehabilitation had better effectiveness and efficiency than those admitted for non-intensive rehabilitation. Younger patients with shorter OAI, lower BIad, and longer LOS realized significantly enhanced effectiveness.

Associations between health-related quality of life, body mass index, health status and sociodemographic variables in geriatric patients and non-hospitalized older people: A comparative cross-sectional study

BACKGROUND

Data on health-related quality of life (HRQoL) in geriatric patients and non-hospitalized older people are lacking, and the associations among HRQoL, body mass index (BMI) and health status are not sufficiently investigated in these groups.

AIM

This study aims to describe and compare HRQoL in a sample of geriatric patients and non-hospitalized people >70 years. It further aims to investigate the associations between HRQoL, BMI, health status and sociodemographic variables in geriatric patients and non-hospitalized people >70 years.

METHODS

This cross-sectional study included 107 geriatric patients and 328 non-hospitalized older people. HRQoL was measured with the 36-Item Short Form Survey (SF-36) and BMI was divided into three classes: underweight (<22 kg/m²), normal weight (22-27 kg/m²) and overweight (>27 kg/m²).

RESULTS

All SF-36 scores were lower for the geriatric patients than for the non-hospitalized people (p < .001). Underweight (BMI <22 kg/m²) was registered for 43.9% of the geriatric patients and for 13.7% of the non-hospitalized people. No significant associations were found between the SF-36 subscale scores and underweight, but overweight was associated with lower scores on physical functioning (B: -8.7) and vitality (B: -6.8) compared to those with normal BMI (p < .05). The participants with rheumatic diseases, pulmonary diseases, hypertension and digestive diseases had significantly lower scores on most SF-36 scales reflecting physical health.

CONCLUSION

HRQoL is substantially lower in geriatric patients than in non-hospitalized older people. The negative effects of both overweight and morbidity on HRQoL indicate that it is important to monitor weight and disease symptoms to promote HRQoL in older people, whether hospitalized or non-hospitalized.

Detailed phenotyping of posterior vs. anterior circulation ischemic stroke: a multi-center MRI study

OBJECTIVE

Posterior circulation ischemic stroke (PCiS) constitutes 20-30% of ischemic stroke cases. Detailed information about differences between PCiS and anterior circulation ischemic stroke (ACiS) remains scarce. Such information might guide clinical decision making and prevention strategies. We studied risk factors and ischemic stroke subtypes in PCiS vs. ACiS and lesion location on magnetic resonance imaging (MRI) in PCiS.

METHODS

Out of 3,301 MRIs from 12 sites in the National Institute of Neurological Disorders and Stroke (NINDS) Stroke Genetics Network (SiGN), we included 2,381 cases with acute DWI lesions. The definition of ACiS or PCiS was based on lesion location. We compared the groups using Chi-squared and logistic regression.

RESULTS

PCiS occurred in 718 (30%) patients and ACiS in 1663 (70%). Diabetes and male sex were more common in PCiS vs. ACiS (diabetes 27% vs. 23%, p < 0.05; male sex 68% vs. 58%, p < 0.001). Both were independently associated with PCiS (diabetes, OR = 1.29; 95% CI 1.04-1.61; male sex, OR = 1.46; 95% CI 1.21-1.78). ACiS more commonly had large artery atherosclerosis (25% vs. 20%, p < 0.01) and cardioembolic mechanisms (17% vs. 11%, p < 0.001) compared to PCiS. Small artery occlusion was more common in PCiS vs. ACiS (20% vs. 14%, p < 0.001). Small artery occlusion accounted for 47% of solitary brainstem infarctions.

CONCLUSION

Ischemic stroke subtypes differ between the two phenotypes. Diabetes and male sex have a stronger association with PCiS than ACiS. Definitive MRI-based PCiS diagnosis aids etiological investigation and contributes additional insights into specific risk factors and mechanisms of injury in PCiS.

Norwegian reference values for the Short Physical Performance Battery (SPPB): the Tromsø Study

Background

The Short Physical Performance Battery (SPPB) is a common well-established instrument to measure physical performance. It involves a timed 4-m walk, timed repeated chair sit-to-stand test, and 10-s balance tests (side-by-side, semi-tandem, and full-tandem). We aimed to establish reference values for community-dwelling Norwegian adults aged 40 years or older in terms of (1) the total score; (2) the three subtest scores; and (3) the time to complete the repeated chair sit-to-stand test and the walking speed. Additionally, we explored floor and ceiling effects for the SPPB.

Methods

The study population comprised home dwellers aged 40 years or more who participated in the 7th wave of the Tromsø study. A sample of 7474 participants (53.2% women) completed the SPPB. Crude mean values and standard deviations (SD) were evaluated according to sex and age group. Mean values at specific ages were then estimated using linear regression, along with corresponding 95% confidence intervals. Additionally, quantile regression was used to estimate age-specific percentiles (5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles).

Results

Considerable variability in SPPB scores was observed. The mean SPPB total score of the entire sample was 11.4 (SD 1.3) points. On average, the SPPB total score was 0.28 points greater in men than in women (p < 0.001). Significant sex differences were observed in all five age groups (40–49, 50–59, 60–69, 70–74, 75–79, and 80+ years). The main decline in the physical function occurred in the mid-sixties, with a slightly earlier decline in women than in men. Ceiling effects were observed in all age groups.

Conclusions

The present study provides comprehensive, up-to-date normative values for SPPB measures in community-dwelling Norwegians aged at least 40 years that may be used to interpret the results of studies evaluating and establishing appropriate treatment goals. Because of ceiling effects, the SPPB has important limitations for the assessment of physical functioning across the full spectrum of the community-dwelling adults aged 40+ years. Furthermore, we conclude that performance on the SPPB should be reported in terms of the total sum score and registered time to complete the repeated chair sit-to stand test and timed 4-m walk test.

Socioeconomic gap between neighborhoods of Budapest: Striking impact on stroke and possible explanations

Introduction

Hungary has a single payer health insurance system offering free healthcare for acute cerebrovascular disorders. Within the capital, Budapest, however there are considerable microregional socioeconomic differences. We hypothesized that socioeconomic deprivation reflects in less favorable stroke characteristics despite universal access to care.

Methods

From the database of the National Health Insurance Fund, we identified 4779 patients hospitalized between 2002 and 2007 for acute cerebrovascular disease (hereafter ACV, i.e. ischemic stroke, intracerebral hemorrhage, or transient ischemia), among residents of the poorest (District 8, n = 2618) and the wealthiest (District 12, n = 2161) neighborhoods of Budapest. Follow-up was until March 2013.

Results

Mean age at onset of ACV was 70±12 and 74±12 years for District 8 and 12 (p<0.01). Age-standardized incidence was higher in District 8 than in District 12 (680/100,000/year versus 518/100,000/year for ACV and 486/100,000/year versus 259/100,000/year for ischemic stroke). Age-standardized mortality of ACV overall and of ischemic stroke specifically was 157/100,000/year versus 100/100,000/year and 122/100,000/year versus 75/100,000/year for District 8 and 12. Long-term case fatality (at 1,5, and 10 years) for ACV and for ischemic stroke was higher in younger District 8 residents (41–70 years of age at the index event) compared to D12 residents of the same age. This gap between the districts increased with the length of follow-up. Of the risk diseases the prevalence of hypertension and diabetes was higher in District 8 than in District 12 (75% versus 66%, p<0.001; and 26% versus 16%, p<0.001).

Discussion

Despite universal healthcare coverage, the disadvantaged district has higher ACV incidence and mortality than the wealthier neighborhood. This difference affects primarily the younger age groups. Long-term follow-up data suggest that inequity in institutional rehabilitation and home-care should be investigated and improved in disadvantaged neighborhoods.

The change of Barthel Index scores from the time of discharge until 3-month post-discharge among acute stroke patients in Malaysia: A random intercept model

Background

Acute stroke results in functional disability measurable using the well-known Barthel Index. The objectives of the study are to describe the change in the Barthel Index score and to model the prognostic factors for Barthel Index change from discharge up to 3 months post-discharge using the random intercept model among patients with acute first ever stroke in Kelantan, Malaysia.

Methods

A total 98 in-hospital first ever acute stroke patients were recruited, and their Barthel Index scores were measured at the time of discharge, at 1 month and 3 months post-discharge. The Barthel Index was scored through telephone interviews. We employed the random intercept model from linear mixed effect regression to model the change of Barthel Index scores during the three months intervals. The prognostic factors included in the model were acute stroke subtypes, age, sex and time of measurement (at discharge, at 1 month and at 3 month post-discharge).

Results

The crude mean Barthel Index scores showed an increased trend. The crude mean Barthel Index at the time of discharge, at 1-month post-discharge and 3 months post-discharge were 35.1 (SD = 39.4), 64.4 (SD = 39.5) and 68.8 (SD = 38.9) respectively. Over the same period, the adjusted mean Barthel Index scores estimated from the linear mixed effect model increased from 39.6 to 66.9 to 73.2. The adjusted mean Barthel Index scores decreased as the age increased, and haemorrhagic stroke patients had lower adjusted mean Barthel Index scores compared to the ischaemic stroke patients.

Conclusion

Overall, the crude and adjusted mean Barthel Index scores increase from the time of discharge up to 3-month post-discharge among acute stroke patients. Time after discharge, age and stroke subtypes are the significant prognostic factors for Barthel Index score changes over the period of 3 months.

Differences in Ischemic Anterior and Posterior Circulation Strokes: A Clinico-Radiological and Outcome Analysis

BACKGROUND

There are limited data comparing posterior (PC) and anterior (AC) circulation acute ischemic strokes (AIS). We aimed to identify specific features of PC and AC strokes regarding clinical, etiological, radiological, and outcome factors.

METHODS

Patients from the Acute STroke Registry and Analysis of Lausanne, a prospective cohort of consecutive AIS, from years 2003 to 2008 were included. The stroke territory was determined by a combination of neuroimaging and clinical symptoms. Patients with uncertain localization or with simultaneous AC and PC strokes were excluded. Multivariate associations between territory and multiple variables were investigated.

RESULTS

A total of 1449 patients were included, 466 (32.2%) had a PC territory stroke and 983 (67.8%) an AC. On multivariate analysis, those with PC AIS had lower National Institutes of Health Stroke Scale at admission, more often showed decreased consciousness, visual field defects, and vestibulo-cerebellar signs, but less hemisyndromes, dysarthria, and cognitive symptoms compared to AC AIS patients. Male sex, arterial dissection, lacunar mechanisms, and endovascular recanalization were more frequent in PC strokes, whereas cardioembolic strokes and IV-thrombolysis rates were lower. Less early ischemic signs on admission CT, overall arterial pathology, and 24-hour recanalization were present in PC strokes but intracranial arterial pathology was more prevalent than in AC. The adjusted clinical outcome at 3 months was similar in both groups.

CONCLUSIONS

In this large retrospective consecutive AIS series, there were specific differences in clinical presentation, etiology, and arterial pathology between PC and AC strokes which did not influence clinical outcome. These findings could lead to a tailored diagnostic work-up, acute treatment strategies, and secondary prevention.

Impact of acute-phase complications and interventions on 6-month survival after stroke. A prospective observational study

The outcome of stroke patients is complex and multidimensional. We evaluated the impact of acute-phase variables, including clinical state, complications, resource use and interventions, on 6-month survival after first-ever stroke, taking into account baseline conditions exerting a possible effect on outcome.

As part of a National Research Program, we performed a prospective observational study of acute stroke patients in four Italian Regions. Consecutive patients admitted for a period of 3 months to the emergency rooms of participating hospitals were included.

A total of 1030 patients were enrolled (median age 76.0 years, 52.1% males). At 6 months, 816 (79.2%) were alive, and 164 (15.9%) deceased. Survival status at the 6-month follow-up was missing for 50 (4.9%). Neurological state in the acute phase was significantly worse in patients deceased at 6 months, who showed also higher frequency of acute-phase complications. Cox regression analysis adjusted for demographics, pre-stroke function, baseline diseases and risk factors, indicated as significant predictors of 6-month death altered consciousness (HR, 1.70; 95% CI, 1.14–2.53), total anterior circulation infarct (HR, 2.13; 95% CI, 1.44–3.15), hyperthermia (HR, 1.70; 95% CI, 1.18–2.45), pneumonia (HR, 1.76; 95% CI, 1.18–2.61), heart failure (HR, 2.87; 95% CI, 1.34–6.13) and nasogastric feeding (HR, 2.35; 95% CI, 1.53–3.60), while antiplatelet therapy during acute phase (HR, 0.56; 95% CI, 0.39–0.79), and early mobilisation (HR, 0.55; 95% CI, 0.36–0.84) significantly increased 6-month survival.

In a prospective observational study, stroke severity and some acute-phase complications, potentially modifiable, significantly increased the risk of 6-month death, independently of baseline variables. Early mobilisation positively affected survival, highlighting the role of early rehabilitation after stroke.

The Impact of Comorbidity on Rehabilitation Outcome after Ischemic Stroke

SUMMARY – Comorbidity decreases survival but it still remains unknown to what extent functional recovery after ischemic stroke is affected. The aim of this research was to determine the prevalence of the most common comorbidities in patients with ischemic stroke and to examine their predictive value on the functional status and recovery. In order to obtain relevant information for this research, we conducted a prospective study over a two-year period. It included patients with acute/subacute ischemic stroke who had inhospital rehabilitation treatment in our institution. Functional status of the patients was evaluated by the following three aspects at the beginning and at the end of rehabilitation treatment: Rivermead Mobility Index was used for mobility, Barthel Index for independence in activities of daily living, and modified Rankin Scale for total disability. Modified Charlston Comorbidity Index was used to assess comorbidity. Multivariate analysis was applied to evaluate the impact of recorded comorbidities on the patient functional outcome. Independent predictors of rehabilitation success in our study were the value of modified Charlston Comorbidity Index, atrial fibrillation and myocardial infarction. Our study demonstrated that patients with more comorbidities had worse functional outcome after stroke, so it is important to consider the comorbidity status when planning the rehabilitation treatment.

Norwegian reference values for the Short-Form Health Survey 36: development over time

Purpose

Reference values for patient-reported outcome measures are useful for interpretation of results from clinical trials. The study aims were to collect Norwegian SF-36 reference values and compare with data from 1996 to 2002.

Methods

In 2015, SF-36 was sent by mail to a representative sample of the population (N = 6165). Time trends and associations between background variables and SF-36 scale scores were compared by linear regression models.

Results

The 2015 response rate was 36% (N = 2118) versus 67% (N = 2323) in 1996 and 56% (N = 5241) in 2002. Only 5% of the youngest (18–29 years) and 27% of the oldest (>70 years) responded in 2015. Age and educational level were significantly higher in 2015 relative to 1996/2002 (p < .001). The oldest age group in 2015 reported better scores on five of eight scales (p < 0.01), the exceptions being bodily pain, vitality, and mental health compared to 1996/2002 (NS). Overall, the SF-36 scores were relatively stable across surveys, controlled for background variables. In general, the most pronounced changes in 2015 were better scores on the role limitations emotional scale (7.4 points, p < .001) and lower scores on the bodily pain scale (4.6 points, p < .001) than in the 1996/2002 survey.

Conclusions

The low response rate in 2015 suggests that the results, especially among the youngest, should be interpreted with caution. The high response rate among the oldest indicates good representativity for those >70 years. Despite societal changes in Norway the past two decades, HRQoL has remained relatively stable.

Recently Uncontrolled Glycemia in Diabetic Patients Is Associated with the Severity of Intracranial Atherosclerosis

BACKGROUND AND PURPOSE

Diabetes mellitus is a specific risk factor for intracranial atherosclerosis (ICAS) regardless of race. However, it is largely unknown whether poor glycemic control is associated with the severity of ICAS in diabetic patients.

METHODS

We selected diabetic patients with acute ischemic stroke who were prospectively registered between March 2005 and December 2015. The patients who had a high-risk source of cardiogenic embolism were excluded. ICAS was graded from 0 to 3 by the number of significant (≥50%) stenoses on intracranial magnetic resonance angiography, and was divided into 4 types: unilateral anterior, bilateral anterior, posterior, and anterior plus posterior. Ordinal and multinomial regression tests were applied for the factors influencing the number and types of ICAS.

RESULTS

A total of 774 patients with noncardioembolic acute ischemic stroke with diabetes were enrolled. The multiplicity of ICAS was independently associated with age (odds ratio [OR], 1.035 per 1 year, 1.018-1.052; P < .001), hypertension (OR, 1.992, 1.336-2.965; P = .001), and glycated hemoglobin (HbA1c; OR, 1.207 per 1%, 1.089-1.338; P < .001) in the ordinal regression model. In multinomial regression, bilateral anterior stenosis tended to be correlated with age (OR, 1.042, 1.008-1.077; P = .016) and HbA1c (OR, 1.201 per 1%, .991-1.520; P = .057). Both anterior and posterior stenoses were significantly associated with age (OR, 1.056, 1.029-1.084; P < .001), hypertension (OR, 2.584, 1.404-4.762; P = .002), and HbA1c (OR, 1.272, 1.070-1.511; P = .006).

CONCLUSIONS

Age, concomitant hypertension, and HbA1c were factors associated with multiple intracranial stenoses. Further study is warranted to elucidate whether poor glycemic control facilitates ICAS in diabetic patients.

mSOAR: an effective bedside stroke prognosis tool

The modified-SOAR (mSOAR) score is composed of the stroke subtype, Oxfordshire Community Stroke Project classification, age, pre-stroke modified Rankin score (mRS) and the National Institutes of Health Stroke Scale score. It has previously been shown to be a reliable predictor of mortality and length of -hospital stay. This study sought to identify whether the mSOAR can also be used to predict patient disability on discharge. A post-hoc calculation of mSOAR using Sentinel Stroke National Audit Programme (SSNAP) data and electronic discharge -summaries was performed on all stroke admissions to Bridgend Hospital over an 11-month period. This study included 230 patients, of which 88% had suffered infarcts and 23% had experienced a previous cerebrovascular episode or transient ischaemic attack; 52% were female. The mortality rate was 13% and 57% had slight disability or less (mRS≤2) on discharge. Each increase in mSOAR score was associated with significantly worse discharge disability (p<0.05). We conclude that the mSOAR score is an excellent tool for predicting both discharge disability and mortality. As such, it's useful for admission prognosis discussions with patients, their relatives and the multidisciplinary team and for early supported discharge decision making.

A lower baseline glomerular filtration rate predicts high mortality and newly cerebrovascular accidents in acute ischemic stroke patients

Chronic kidney disease (CKD) is gradually recognized as an independent risk factor for cardiovascular and cardio-/cerebrovascular disease. This study aimed to examine the association of the estimated glomerular filtration rate (eGFR) and clinical outcomes at 3 months after the onset of ischemic stroke in a hospitalized Chinese population.Totally, 972 patients with acute ischemic stroke were enrolled into this study. Modified of Diet in Renal Disease (MDRD) equations were used to calculate eGFR and define CKD. The site and degree of the stenosis were examined. Patients were followed-up for 3 months. Endpoint events included all-cause death and newly ischemic events. The multivariate logistic model was used to determine the association between renal dysfunction and patients' outcomes.Of all patients, 130 patients (13.4%) had reduced eGFR (<60 mL/min/1.73 m), and 556 patients had a normal eGFR (≥90 mL/min/1.73 m). A total of 694 patients suffered from cerebral artery stenosis, in which 293 patients only had intracranial artery stenosis (ICAS), 110 only with extracranial carotid atherosclerotic stenosis (ECAS), and 301 with both ICAS and ECAS. The patients with eGFR <60 mL/min/1.73m had a higher proportion of death and newly ischemic events compared with those with a relatively normal eGFR. Multivariate analysis revealed that a baseline eGFR <60 mL/min/1.73 m increased the risk of mortality by 3.089-fold and newly ischemic events by 4.067-fold. In further analysis, a reduced eGFR was associated with increased rates of mortality and newly events both in ICAS patients and ECAS patients. However, only an increased risk of newly events was found as the degree of renal function deteriorated in ICAS patients (odds ratio = 8.169, 95% confidence interval = 2.445-14.127).A low baseline eGFR predicted a high mortality and newly ischemic events at 3 months in ischemic stroke patients. A low baseline eGFR was also a strong independent predictor for newly ischemic events in ICAS patients.

Posterior versus Anterior Circulation Stroke in Young Adults: A Comparative Study of Stroke Aetiologies and Risk Factors in Stroke among Young Fabry Patients (sifap1)

BACKGROUND

Although 20-30% of all strokes occur in the posterior circulation, few studies have explored the characteristics of patients with strokes in the posterior compared to the anterior circulation so far. Especially data on young patients is missing.

METHODS

In this secondary analysis of data of the prospective multi-centre European sifap1 study that investigated stroke and transient ischemic attack (TIA) patients aged 18-55 years, we compared vascular risk factors, stroke aetiology, presence of white matter hyperintensities (WMH) and cerebral microbleeds (CMB) between patients with ischaemic posterior circulation stroke (PCS) and those having suffered from anterior circulation stroke (ACS) based on cerebral MRI.

RESULTS

We diagnosed PCS in 612 patients (29.1%, 407 men, 205 women) and ACS in 1,489 patients (70.9%). Their age (median 46 vs. 47 years, p = 0.205) and stroke severity (modified Rankin Scale: both 2, p = 0.375, Barthel Index 90 vs. 85, p = 0.412) were similar. PCS was found to be more frequent among the male gender (66.5 vs. 60.1% with ACS, p = 0.003). Vertebral artery (VA) dissection was more often the cause of PCS (16.8%) than was carotid artery dissection of ACS (7.9%, p < 0.001). Likewise, small vessel disease (Trial of Org 10172 in Acute Stroke Treatment [TOAST] = 3, PCS: 14.7%, ACS: 11.8%) and stroke of other determined aetiology (TOAST = 4, PCS: 24.5%, ACS: 16.0%) were more frequent in those with PCS. Furthermore, patent foramen ovale (PFO; PCS: 31.1%, ACS: 25.4%, p = 0.029) was more often detected in patients with PCS. In contrast, large-artery atherosclerosis (TOAST = 1, PCS: 15.4%, ACS: 22.2%) and cardio-embolic stroke (TOAST = 2, PCS: 15.6%, ACS: 18.0%) were less frequent in those with PCS (p < 0.001) as were preceding cerebrovascular events (10.1 vs. 14.1%, p = 0.014), TIA (4.8 vs. 7.7%, p = 0.016) and smoking (53.2 vs. 61.0%, p = 0.001). The presence, extent, and location of WMH and CMB did not differ between the 2 groups.

CONCLUSIONS

Our data suggested a different pattern of aetiology and risk factors in young patients with PCS compared to those with ACS. These findings especially call for a higher awareness of VA dissection and potentially for more weight of a PFO as a risk factor in young patients with PCS. Clinical trial registration-URL: http://www.clinicaltrials.gov; NCT00414583.

Prevalence of factors associated with malnutrition among acute geriatric patients in Norway: a cross-sectional study

OBJECTIVES

Data on acute geriatric patients' nutritional status are lacking, and the associations among physical function, sarcopenia, health status and nutritional status are not sufficiently investigated in this population. The aims of this study are to investigate (1) nutritional status and sarcopenia in a group of acute geriatric patients, (2) the association between nutritional status, physical function and sarcopenia in acute geriatric patients, controlling for health status.

DESIGN

A cross-sectional study.

SETTING

Two acute geriatric hospital wards in Norway.

PARTICIPANTS

This study included 120 patients with a mean age of 82.6±8 years. The following inclusion criteria were used: age ≥65 years and admitted to an acute geriatric ward. The exclusion criteria included terminal illness, Mini-Mental State Examination <23, language difficulties or severe aphasia.

MAIN OUTCOME MEASURES

Nutritional status was assessed using the Mini Nutritional Assessment (MNA). Physical function was measured using the Barthel activities of daily life index and the Short Physical Performance Battery (SPPB). Sarcopenia was diagnosed using the mid-arm muscle circumference, gait speed and grip strength, in accordance with the EWGSOP algorithm. Diseases are organised by organ system classification.

RESULTS

On the basis of the MNA classification, nearly one in two patients were at risk of malnutrition, while one in four were malnourished. Sarcopenia was present in 30% of the patients. A multivariate linear regression model was estimated and showed significant independent associations between SPPB score (β 0.64, 95% CI 0.38 to 0.90), sarcopenia (β -3.3, 95% CI -4.9 to -1.7), pulmonary disease (β -2.1, 95% CI -3.7 to -0.46), cancer (β -1.7, 95% CI -3.4 to -0.033) and nutritional status.

CONCLUSIONS

Our study shows a high prevalence of risk of malnutrition, malnutrition and sarcopenia. Further, the results indicate that a low total SPPB score, sarcopenia, cancer and pulmonary disease are significantly associated with declines in nutritional status, as measured by the MNA, in acute geriatric patients.

PPARG gene C161T CT/TT associated with lower blood lipid levels and ischemic stroke from large-artery atherosclerosis in a Han population in Guangdong

OBJECTIVE

Peroxisome proliferator-activated receptor gamma (PPARG) is a transcription factor involved in atherosclerosis and related diseases. In this study, we aimed to investigate whether PPARG C161T was associated with lipid levels and large-artery atherosclerosis (LAA) ischemic stroke in a Han Chinese population in Guangdong province.

METHODS

The genotype PPARG C161T in 149 LAA ischemic stroke patients and 125 healthy controls was examined by polymerase chain reaction-restriction fragment length polymorphism (RFLP) assay. Associations with LAA ischemic stroke were analyzed for PPARG C161T genotype, total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C), and a logistic regression analysis was performed to identify risk factors for LAA ischemic stroke.

RESULTS

The frequency of CC was higher than that of CT + TT and was significantly associated with LAA ischemic stroke. In both the LAA and control groups, TC and LDL-C levels were significantly higher in the CC type than the CT + TT, but TG and HDL-C levels were comparable. The only verified independent risk factors for LAA ischemic stroke were ischemic heart disease (OR: 2.784, 95% CI: 1.377-5.632; p = 0.004) and systolic blood pressure (OR: 1.014, 95% CI: 1.001-1.026; p = 0.029); the PPARG C161T allele was not independently associated with an increased risk of LAA ischemic stroke (OR = 0.697, 95% CI: 0.372-1.305; p = 0.260).

CONCLUSION

In this Han population, PPARG C161T CT/TT was associated with LAA ischemic stroke and lower levels of blood TC and LDL-C, but was not an independent risk factor for LAA ischemic stroke.

Relationship between pre-stroke cardiovascular medication use and stroke severity

INTRODUCTION

Stroke is a major health problem with important morbidity and mortality. Various risk factors and cardiovascular medication groups are known to have an influence on stroke incidence, but less is known about the relation between medication use and stroke severity.

AIM

To determine if relationships exist between the pre-stroke cardiovascular medication use and stroke severity.

METHODS

A retrospective study was conducted on a database with anonymized data of 1974 patients with a suspected stroke, admitted to the Universitair Ziekenhuis (UZ) Brussel. Stroke severity was quantified using the National Institute of Health Stroke Scale (NIHSS). Cardiovascular medication groups were first included in a multivariable linear regression model. Second, to obtain clinically interpretable results, all variables that were retained in the final linear regression model were introduced in a cumulative odds ordinal logistic regression model with proportional odds.

RESULTS

Angiotensin II receptor blockers (ARBs), statins, and antiarrhythmics were significantly associated with stroke severity at the 10 % α level in a multivariable linear regression model, suggesting a possible effect of these medication groups on stroke severity. Only pre-stroke statin use showed a significant relationship with the NIHSS score in the ordinal logistic regression model with an adjusted odds ratio of 0.740 (95 % CI 0.580-0.944; p = 0.015).

CONCLUSION

Pre-stroke use of statins is significantly associated with lower stroke severity. No significant relationship was detected between pre-stroke use of other medication groups and stroke severity, defined by the NIHSS score.

The Impact of Diagnosing Branch Atheromatous Disease for Predicting Prognosis

BACKGROUND

We had reported that, in the acute phase of the brain penetrating artery infarction, patients with branch atheromatous disease (BAD) tended to be worsened compared with the lacunar infarction (LI). Because no prospective study has been reported, we composed a multicenter study (Japan Branch Atheromatous Disease [J-BAD] Registry) in which patients of penetrating artery infarction were prospectively enrolled for exploring the clinical features of BAD.

METHODS

From the associated 9 hospitals, acute ischemic stroke patients were asked to be enrolled in the J-BAD Registry and classified into the lenticulostriate arterial (LSA) infarction (n = 124) and the pontine penetrating arterial (PPA) infarction (n = 42) groups. The clinical courses and the repeated magnetic resonance imaging findings were investigated.

RESULTS

Neurologic worsening was observed at a significantly higher rate in BAD compared with the LI patients in both the LSA and PPA groups (P < .01, 45.1% versus 22.6% and 46.7% versus 0%, respectively). In the LSA group, the enlargement of the ischemic lesion was significantly more frequent in BAD compared with the LI patients (P < .01, 66.2% and 34.0%, respectively). There was a significant relation between the enlargement of the lesion and the worsening of neurologic deficits (P < .001). Moreover, the clinical features, which predict the lesion enlargement, were BAD and older age.

CONCLUSIONS

LSA infarction of BAD diagnosis or older age patients might show an increase of lesion size and a tendency of neurologic worsening. It could be important to discriminate BAD from other ischemic stroke subtypes, in regard to the prediction of prognosis.

Risk Factors for Ischemic Stroke and its Subtypes in Chinese vs. Caucasians: Systematic Review and Meta-Analysis

Background

Chinese populations are reported to have a different distribution of ischemic stroke subtypes compared with Caucasians.

Aims

To understand this better, we aimed to evaluate the differences in prevalence of risk factors in ischemic stroke and their distributions among ischemic stroke subtypes in Chinese vs. Caucasians.

Summary or review

We systematically sought studies conducted since 1990 with data on frequency of risk factors among ischemic stroke subtypes in Chinese or Caucasians. For each risk factor, we calculated study-specific and random effects pooled estimates in Chinese and Caucasians separately for: prevalence among ischemic stroke; odds ratios, comparing prevalence for each ischemic stroke subtype vs. all others. We included seven studies among 16 199 Chinese, and eleven among 16 189 Caucasian ischemic stroke patients. Risk factors studied were hypertension, diabetes, atrial fibrillation, ischemic heart disease, hypercholesterolemia, smoking and alcohol. Chinese ischemic stroke patients had younger onset of stroke than Caucasians, similar prevalence of hypertension, diabetes, smoking and alcohol, and significantly lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia. Risk factor associations with ischemic stroke subtypes were mostly similar among Chinese and Caucasian ischemic stroke patients. Compared with all other ischemic subtypes, diabetes was more common in large artery stroke, atrial fibrillation and ischemic heart disease in cardioembolic stroke, and hypertension and diabetes in lacunar stroke.

Conclusion

Our study showed a lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia in Chinese, and mostly similar risk factor associations in Chinese and Caucasian ischemic stroke patients. Further analyses of individual patient data to allow adjustment for confounders are needed to confirm and extend these findings.

Etiology and Risk Factors of Posterior Circulation Infarction Compared with Anterior Circulation Infarction

BACKGROUND

Many clinicians regard posterior circulation infarction (PCI) as different from anterior circulation infarction (ACI), leading them to apply different treatments. Few studies have validated this practice by directly comparing the etiology and risk factors of PCI and ACI.

METHODS

We compared the etiology and risk factors of 2245 consecutive patients with a diagnosis of PCI or ACI confirmed by magnetic resonance imaging in the Chengdu Stroke Registry. Stroke etiology in each patient was classified according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.

RESULTS

Our sample included 482 patients (21.5%) with PCI and 1763 (78.5%) with ACI. The most frequent etiology for both infarction types was small-artery occlusion, occurring in 37.6% of patients with PCI and 37.1% of those with ACI. Cardioembolism caused infarction in a significantly smaller proportion of patients with PCI (5.4%) than in patients with ACI (13.3%; odds ratio [OR] = .373; 95% confidence interval [CI], .245-.566). Frequencies of other stroke etiologies were similar between the 2 patient groups. Analysis of risk factor frequencies in the 2 groups showed hypertension to be the most common, occurring in 47.9% of patients in either group. Multivariable analysis identified 2 factors as conferring greater risk of PCI than ACI: male gender (OR = 1.392; 95% CI, 1.085-1.786) and diabetes mellitus (OR = 1.667; 95% CI, 1.275-2.180). The same analysis identified 2 factors as conferring greater risk of ACI: atrial fibrillation (OR = .530; 95% CI, .295-.951) and heart valve disease (OR = .433; 95% CI, .203-.922). Frequencies of other possible risk factors were similar between the 2 groups.

CONCLUSIONS

These findings suggest that PCI and ACI are more similar than different in their etiology and risk factors and that the 2 types of infarction should be treated based more on etiology and risk factors than on their posterior or anterior localization.

Prevention and management of stroke in women

Stroke is the leading cause of acquired disability and the third leading cause of death in women worldwide. Sex differences in risk factors, treatment response and quality of life after stroke complicate stroke management in women. Women have an increased lifetime incidence of stroke compared to men, largely due to a sharp increase in stroke risk in older postmenopausal women. Women also have an increased lifetime prevalence of stroke risk factors, including hypertension and atrial fibrillation in postmenopausal women, as well as abdominal obesity and metabolic syndrome in middle-aged women. Controversy continues over the risks of oral contraceptives, hormone therapy and surgical intervention for carotid stenosis in women. Pregnancy and the postpartum period represent a time of increased risk, presenting challenges to stroke management. Recognition of these issues is critical to improving acute care and functional recovery after stroke in women.

Factors affecting clinical outcome in large-vessel occlusive ischemic strokes

Clinical outcome after large-vessel occlusive strokes depends on admitting clinical condition, successful recanalization, and robust collateral circulation. However, predicting successful recanalization and quantifying collateral status in the acute setting remain elusive. Successful recanalization has many predictive factors. Strong evidence supports increasing clot length being associated with poor recanalization. Current imaging techniques completed in the acute setting suggest that clot length can be estimated with a clot burden score. In vitro evidence suggests that clots with more red blood cells and less thrombin lyse more easily after systemic fibrinolysis. Clinical correlations with clot composition have been mixed, although one study suggested that clot composition could be predicted with computed tomography and correlate with successful recanalization. Finally, overwhelming proof shows that robust collateral circulation correlates with improved clinical outcome. Imaging modalities in the acute setting remain promising, with studies suggesting that collaterals can be quantified with computed tomography angiography and perfusion studies. Patients with large-vessel occlusive strokes have variable clinical responses to fibrinolysis and thrombectomy. Independent predictive variables that can possibly alter clinical outcome appear to be successful recanalization and robust collateral circulation. Future studies that allow for better prediction of successful recanalization and quantification of collateral status may help clinical decision-making when evaluating large-vessel occlusions.

Revised iScore to predict outcomes after acute ischemic stroke

The iScore is a validated tool to predict mortality and functional outcome after acute ischemic stroke. It incorporates stroke subtype according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification as one of its factors. However, the TOAST stroke subtype may not be easily determined without extensive investigations. We aimed to test if the stroke subtype can be substituted by the Oxfordshire Community Stroke Project (OCSP) classification. We applied the iScore and the revised iScore, in which the TOAST subtype was replaced by the OCSP classification, to patients admitted to a single hospital for acute ischemic stroke. Outcome measures included poor functional status (modified Rankin scale score, 3-6) at discharge and 3 months. The performance between the iScore and the revised iScore was assessed by determining the discrimination and calibration of the scores. We studied 3196 patients at the acute stage, and among them 2349 patients were available for the 3-month assessment. The discrimination of the revised iScore was comparable with the iScore for poor outcome at discharge (area under the receiver operating characteristic curve, .767 versus .775; P=.06) and at 3-month (.801 versus .810; P=.06). The correlation between the observed and the expected outcomes was high for both the iScore (Pearson correlation coefficient, .993 at discharge and .995 at 3 months; both P<.0001) and the revised iScore (.985 and .993, respectively; both P<.0001). The revised iScore reliably predicts clinical outcomes at discharge and 3 months for patients with acute ischemic stroke.

Risk adjustment of ischemic stroke outcomes for comparing hospital performance: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke is the fourth-leading cause of death and a leading cause of long-term major disability in the United States. Measuring outcomes after stroke has important policy implications. The primary goals of this consensus statement are to (1) review statistical considerations when evaluating models that define hospital performance in providing stroke care; (2) discuss the benefits, limitations, and potential unintended consequences of using various outcome measures when evaluating the quality of ischemic stroke care at the hospital level; (3) summarize the evidence on the role of specific clinical and administrative variables, including patient preferences, in risk-adjusted models of ischemic stroke outcomes; (4) provide recommendations on the minimum list of variables that should be included in risk adjustment of ischemic stroke outcomes for comparisons of quality at the hospital level; and (5) provide recommendations for further research.

METHODS AND RESULTS

This statement gives an overview of statistical considerations for the evaluation of hospital-level outcomes after stroke and provides a systematic review of the literature for the following outcome measures for ischemic stroke at 30 days: functional outcomes, mortality, and readmissions. Data on outcomes after stroke have primarily involved studies conducted at an individual patient level rather than a hospital level. On the basis of the available information, the following factors should be included in all hospital-level risk-adjustment models: age, sex, stroke severity, comorbid conditions, and vascular risk factors. Because stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor of hospital-level performance for 30-day mortality, inclusion of a stroke severity measure in risk-adjustment models for 30-day outcome measures is recommended. Risk-adjustment models that do not include stroke severity or other recommended variables must provide comparable classification of hospital performance as models that include these variables. Stroke severity and other variables that are included in risk-adjustment models should be standardized across sites, so that their reliability and accuracy are equivalent. There is a pressing need for research in multiple areas to better identify methods and metrics to evaluate outcomes of stroke care.

CONCLUSIONS

There are a number of important methodological challenges in undertaking risk-adjusted outcome comparisons to assess the quality of stroke care in different hospitals. It is important for stakeholders to recognize these challenges and for there to be a concerted approach to improving the methods for quality assessment and improvement.

Aroma and taste perceptions with Alzheimer disease and stroke

Chemosensory disorders of smell or taste in humans have been attributed to various physiological and environmental factors including aging and disease conditions. Aroma and taste greatly condition our food preference, selection and, consumption; the decreased appetite in patients with known neurodegenerative diseases may lead to dietary restrictions that could negatively impact nutritional and health status. The decline in olfactory and gustatory systems in patients with Alzheimer disease and various types of stroke are described.

The association between circulating endothelial progenitor cells and outcome in different subtypes of acute ischemic stroke

OBJECTIVES

This study evaluated the relationship between serial changes in circulating endothelial progenitor cells (EPCs) and outcomes in patients with different subtypes of acute ischemic stroke (AIS).

METHODS

This prospective cohort study evaluated 65 patients with AIS, including 45 with small-vessel and 20 with large-vessel diseases. The circulating level of EPCs (CD133(+)/CD34(+) and KDR(+)/CD34(+) cells) was determined at different time points (within 48h and on Days 7 and 30 post-stroke). For comparison, the EPC levels of 65 age- and sex-matched controls were also evaluated.

RESULTS

The levels of CD133(+)/CD34(+) and KDR(+)/CD34(+) EPCs were significantly lower in the AIS group than in the control group (p<0.05). There were fewer CD133(+)/CD34(+) EPCs in the large-vessel disease group than in the small-vessel disease group on Day 1 post-stroke (p<0.05). After adjusting for covariance using stepwise logistic regression, only stroke subtype (OR: 30.2, 95% CI: 5.3-171.4; p<0.001) and KDR(+)/CD34(+) on admission (OR: 0.188, 95% CI: 0.04-0.86; p=0.031) were independently associated with 6-month outcome.

CONCLUSIONS

The number of circulating EPCs is significantly lower in patients with large-vessel disease than in those with small-vessel disease. Fewer number of EPCs on admission is an independent risk factor for poor 6-month outcome in patients with AIS.

Educational levels and the functional dependence of ischemic stroke survivors

We evaluated the functional dependence of stroke survivors from the Study of Stroke Mortality and Morbidity, using the Rankin Scale. Out of 355 ischemic stroke survivors (with a mean age of 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days. These predictors were: low levels of education [illiterate vs. ≥ 8 years of education, multivariate odds ratio (OR) = 3.7; 95% confidence interval (95%CI): 1.60-8.54] and anatomical stroke location (total anterior circulation infarct, OR = 16.9; 95%CI: 2.93-97.49). Low levels of education and ischemic brain injury influenced functional dependence in these stroke survivors. Our findings reinforce the necessity of developing strategies for the rehabilitation of stroke patients, more especially in formulating specific strategies for care and treatment of stroke survivors with low socioeconomic status.

Update on acute endovascular and surgical stroke treatment

Emergency stroke care has become a natural part of the emerging discipline of neurocritical care and demands close cooperation between the neurologist and neurointerventionists, neurosurgeons, and anesthesiologists. Endovascular treatment (EVT), including intra-arterial thrombolysis, mechanical thrombectomy and angioplasty/stenting, is under rapid development. Although EVT has yet to be shown in randomized controlled trials to improve clinical outcome compared to intravenous thrombolysis, it is far better in achieving recanalization of occluded large cerebral vessels, which is crucial for rescuing the penumbra. Moreover, decompressive craniectomy is now a well-established treatment option for malignant middle cerebral artery infarction and cerebellar stroke. Using a case-based approach, this article reviews recent achievements in advanced treatment options for patients with acute ischemic stroke.

International Paediatric Stroke Study: stroke associated with cardiac disorders

BACKGROUND AND HYPOTHESIS

The aetiologies of arterial ischaemic stroke in children are diverse and often multifactorial. A large proportion occurs in children with cardiac disorders. We hypothesized that the clinical and radiographic features of children with arterial ischaemic stroke attributed to cardiac disorders would differ from those with other causes.

METHODS

Using the large population collected in the prospective International Paediatric Stroke Study, we analysed the characteristics, clinical presentations, imaging findings, and early outcomes of children with and without cardiac disorders.

RESULTS

Aetiological data were available for 667 children with arterial ischaemic stroke (ages 29 days to 19 years). Cardiac disorders were indentified in 204/667 (30.6%), congenital defects in 121/204 (59.3%), acquired in 40/204 (19.6%), and isolated patent foramen ovale in 31/204 (15.2%). Compared to other children with stroke, those with cardiac disorders were younger (median age 3.1 vs. 6.5 years; P < 0.001) and less likely to present with headache (25.6% vs. 44.6%; P < 0.001), but were similar in terms of gender and presentation with focal deficits, seizures, or recent infection. Analysis of imaging data identified significant differences (P = 0.005) in the vascular distribution (anterior vs. posterior circulation or both) between groups. Bilateral strokes and haemorrhagic conversion were more prevalent in the cardiac disorders group.

CONCLUSIONS

Cardiac disorders were identified in almost one-third of children with arterial ischaemic stroke. They had similar clinical presentations to those without cardiac disorders but differed in age and headache prevalence. Children with cardiac disorders more frequently had a 'cardioembolic stroke pattern' with a higher prevalence of bilateral strokes in both the anterior and posterior circulations, and a greater tendency to haemorrhagic transformation.