1
|
Armario P, Gómez-Choco M, García-Sánchez SM, Ruilope LM, Williams B, de la Sierra A. Clinic and ambulatory blood pressures, blood pressure phenotypes and mortality in patients with a previous stroke. Hypertens Res 2024:10.1038/s41440-024-01760-1. [PMID: 38918531 DOI: 10.1038/s41440-024-01760-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/09/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024]
Abstract
There is scarce evidence of the role of clinic and ambulatory BP indices, as well as blood pressure phenotypes in the prognosis of stroke survivors. We aimed to evaluate the association between ambulatory BP indices and mortality in patients with a previous stroke. Our study was an observational cohort study from individuals included in the Spanish Ambulatory Blood Pressure Registry from March 2004 to December 2014. The Cox model was used to estimate associations between usual clinic and ambulatory BP and mortality, adjusted for confounders and additionally for alternative measures of BP. Two thousand one hundred and eighty-three patients with a previous stroke were included. During a median of 9.2 years, 632 (28.9%) patients died: 236 (10.8%) from cardiovascular causes. In the confounder-adjusted model, clinic systolic BP was not associated with the risk of all-cause or cardiovascular mortality. In contrast, systolic BP indices obtained through ABPM (24 h, day and night) were all associated with all-cause and cardiovascular death. In the simultaneous adjustment of daytime and night-time systolic BP, only night-time systolic BP remained significantly associated with all-cause and cardiovascular death: HR 1.35 (95% CI 01.21-1.51) and 1.44 (1.20-1.72), respectively. For diastolic BP, only night-time BP was associated with all-cause and cardiovascular mortality: HR 1.32 (1.18-1.48) and 1.57 (1.31-1.88), respectively. According to the circadian pattern, a riser pattern was associated with all-cause and cardiovascular mortality: HR 1.49 (1.18-1.87) and 1.70 (1.14-2.52), respectively. In conclusion, in patients who have suffered a stroke, night-time BP is the BP estimate most closely associated with all-cause and cardiovascular mortality.
Collapse
Affiliation(s)
- Pedro Armario
- Department of Internal Medicine, Cardiovascular Risk Area, Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, University of Barcelona, Barceloncoa, Spain.
| | - Manuel Gómez-Choco
- Department of Neurology, Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, University of Barcelona, Barcelona, Spain
| | - Sonia M García-Sánchez
- Department of Neurology, Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, University of Barcelona, Barcelona, Spain
| | - Luis M Ruilope
- Hypertension Unit and Cardiorenal Translational Laboratory, Hospital 12 de Octubre, Madrid, Spain
| | - Bryan Williams
- University College London (UK) Institute of Cardiovascular Science and National Institute for Health Research (NIHR) UCL Hospitals Biomedical Research Centre, London, UK
| | - Alejandro de la Sierra
- Hypertension Unit. Department of Internal Medicine. Hospital Mutua Terrassa. University of Barcelona, Terrassa, Spain
| |
Collapse
|
2
|
Singh B, Huang D. The Role of Circadian Rhythms in Stroke: A Narrative Review. Neurochem Res 2024; 49:290-305. [PMID: 37838637 DOI: 10.1007/s11064-023-04040-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/12/2023] [Accepted: 09/24/2023] [Indexed: 10/16/2023]
Abstract
Stroke, a debilitating condition often leading to long-term disability, poses a substantial global concern and formidable challenge. The increasing incidence of stroke has drawn the attention of medical researchers and neurologists worldwide. Circadian rhythms have emerged as pivotal factors influencing stroke's onset, pathogenesis, treatment, and outcomes. To gain deeper insights into stroke, it is imperative to explore the intricate connection between circadian rhythms and stroke, spanning from molecular mechanisms to pathophysiological processes. Despite existing studies linking circadian rhythm to stroke onset, there remains a paucity of comprehensive reviews exploring its role in pathogenesis, treatment, and prognosis. This review undertakes a narrative analysis of studies investigating the relationship between circadian variation and stroke onset. It delves into the roles of various physiological factors, including blood pressure, coagulation profiles, blood cells, catecholamines, cortisol, and the timing of antihypertensive medication, which contribute to variations in circadian-related stroke risk. At a molecular level, the review elucidates the involvement of melatonin, circadian genes, and glial cells in the pathophysiology. Furthermore, it provides insights into the diverse factors influencing stroke treatment and outcomes within the context of circadian variation. The review underscores the importance of considering circadian rhythms when determining the timing of stroke interventions, emphasizing the necessity for personalized stroke management strategies that incorporate circadian rhythms. It offers valuable insights into potential molecular targets and highlights areas that require further exploration to enhance our understanding of the underlying pathophysiology. In comparison to the published literature, this manuscript distinguishes itself through its coverage of circadian rhythms' impact on stroke across the entire clinical spectrum. It presents a unique synthesis of epidemiological, clinical, molecular, and cellular evidence, underscoring their collective significance.
Collapse
Affiliation(s)
- Bivek Singh
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.
- Department of Medicine, National Cardiac Centre, Basundhara, Kathmandu, , Bagmati Province, Nepal.
| | - Dongya Huang
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| |
Collapse
|
3
|
Ding X, Zhou Y, Pan Y, Xu J, Yan H, Zhao X, Wang Y, Wang Y. Dipping Pattern and 1-year stroke functional outcome in ischemic stroke or transient ischemic attack. Clin Exp Hypertens 2023; 45:2139384. [DOI: 10.1080/10641963.2022.2139384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Xia Ding
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilun Zhou
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| |
Collapse
|
4
|
Sreekrishnan A, Seners P, Yuen N, Olivot JM, Mlynash M, Lansberg MG, Heit JJ, Lee S, Michel P, Strambo D, Salerno A, Paredes JBE, Carrera E, Albers GW. Elevated Hypoperfusion Intensity Ratio (HIR) observed in patients with a large vessel occlusion (LVO) presenting in the evening. J Stroke Cerebrovasc Dis 2023; 32:107172. [PMID: 37196564 PMCID: PMC10524823 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107172] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/25/2023] [Accepted: 05/08/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Circadian variability has been implicated in timing of stroke onset, yet the full impact of underlying biological rhythms on acute stroke perfusion patterns is not known. We aimed to describe the relationship between time of stroke onset and perfusion profiles in patients with large vessel occlusion (LVO). METHODS A retrospective observational study was conducted using prospective registries of four stroke centers across North America and Europe with systematic use of perfusion imaging in clinical care. Included patients had stroke due to ICA, M1 or M2 occlusion and baseline perfusion imaging performed within 24h from last-seen-well (LSW). Stroke onset was divided into eight hour intervals: (1) Night: 23:00-6:59, (2) Day: 7:00-14:59, (3) Evening: 15:00-22:59. Core volume was estimated on CT perfusion (rCBF <30%) or DWI-MRI (ADC <620) and the collateral circulation was estimated with the Hypoperfusion Intensity Ratio (HIR = [Tmax>10s]/[Tmax>6s]). Non-parametric testing was conducted using SPSS to account for the non-normalized dependent variables. RESULTS A total of 1506 cases were included (median age 74.9 years, IQR 63.0-84.0). Median NIHSS, core volumes, and HIR were 14.0 (IQR 8.0-20.0), 13.0mL (IQR 0.0-42.0), and 0.4 (IQR 0.2-0.6) respectively. Most strokes occurred during the Day (n = 666, 44.2%), compared to Night (n = 360, 23.9%), and Evening (n = 480, 31.9%). HIR was highest, indicating worse collaterals, in the Evening compared to the other timepoints (p = 0.006). Controlling for age and time to imaging, Evening strokes had significantly higher HIR compared to Day (p = 0.013). CONCLUSION Our retrospective analysis suggests that HIR is significantly higher in the evening, indicating poorer collateral activation which may lead to larger core volumes in these patients.
Collapse
Affiliation(s)
| | - Pierre Seners
- Department of Neurology, Stanford Hospital, Palo Alto, CA, USA; Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France; Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Paris, France
| | - Nicole Yuen
- Department of Neurology, Stanford Hospital, Palo Alto, CA, USA
| | - Jean-Marc Olivot
- Department of Neurology and UMR Clinical investigating Center 1436 Centre Hospitalier Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Michael Mlynash
- Department of Neurology, Stanford Hospital, Palo Alto, CA, USA
| | | | - Jeremy J Heit
- Department of Neurosurgery, Stanford Hospital, Palo Alto, CA, USA
| | - Sarah Lee
- Department of Neurology, Stanford Hospital, Palo Alto, CA, USA
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital, Lausanne, Switzerland
| | - Davide Strambo
- Department of Neurology, Lausanne University Hospital, Lausanne, Switzerland
| | - Alexander Salerno
- Department of Neurology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Emmanuel Carrera
- Department of Neurology, Geneva University Hospital, Geneva, Switzerland
| | | |
Collapse
|
5
|
Kakaletsis N, Ntaios G, Milionis H, Karagiannaki A, Chouvarda I, Dourliou V, Ladakis I, Kaiafa G, Vemmos K, Savopoulos C. Midday Dipping and Circadian Blood Pressure Patterns in Acute Ischemic Stroke. J Clin Med 2023; 12:4816. [PMID: 37510931 PMCID: PMC10381256 DOI: 10.3390/jcm12144816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
The purpose of this study was to investigate the alterations in blood pressure (BP) during midday and the changes in circadian BP patterns in the acute phase of ischemic stroke (AIS) with the severity of stroke and their predictive role outcomes within 3 months. A total of 228 AIS patients (a prospective multicenter follow-up study) underwent 24 h ambulatory blood pressure monitoring (ABPM). Mean BP parameters during the day (7:00-22:59), the midday (13:00-16:59), and the night (23:00-6:59), and midday and nocturnal dipping were calculated. Midday SBP dippers had less severe stroke, lower incidence of hypertension and SBP/DBP on admission, lower levels of serum glucose and WBCs, and delayed initiation of ABPM compared to risers. There was a reverse relation between midday SBP dipping and both nocturnal dipping and stroke severity. The "double dippers" (midday and nocturnal dipping) had the least severe stroke, the lowest SBP/DBP on admission, the lowest heart rate from ABPM, and a lower risk of an unfavorable outcome, while the "double risers" had the opposite results, by an approximately five-fold risk of death/disability at 3 months. These findings indicate different circadian BP patterns during the acute phase of AIS, which could be considered a marker of stroke severity and prognosis.
Collapse
Affiliation(s)
- Nikolaos Kakaletsis
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 35100 Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Medical School, University of Ioannina, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Anastasia Karagiannaki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 35100 Larissa, Greece
| | - Ioanna Chouvarda
- Laboratory of Computing, Medical Informatics and Biomedical-Imaging Technologies, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Vasiliki Dourliou
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
| | - Ioannis Ladakis
- Laboratory of Computing, Medical Informatics and Biomedical-Imaging Technologies, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Georgia Kaiafa
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
| | | | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
| |
Collapse
|
6
|
Kakaletsis N, Ntaios G, Milionis H, Karagiannaki A, Chouvarda I, Dourliou V, Chytas A, Hatzitolios AI, Savopoulos C. Prognostic significance of 24-h blood pressure and variability indices in the outcome of acute ischaemic stroke. Intern Med J 2023; 53:1137-1146. [PMID: 35666577 DOI: 10.1111/imj.15834] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The association between blood pressure (BP) levels and BP variability (BPV) following acute ischaemic stroke (AIS) and outcome remains controversial. AIMS To investigate the predictive value of systolic BP (SBP) and diastolic BP (DBP) and BPV measured using 24-h ambulatory blood pressure monitoring (ABPM) methods during AIS regarding outcome. METHODS A total of 228 AIS patients (175 without prior disability) underwent ABPM every 20 min within 48 h from onset using an automated oscillometric device (TM 2430, A&D Company Ltd) during day time (7:00-22:59) and night time (23:00-6:59). Risk factors, stroke subtypes, clinical and laboratory findings were recorded. Mean BP parameters and several BPV indices were calculated. End-points were death and unfavourable functional outcome (disability/death) at 3 months. RESULTS A total of 61 (26.7%) patients eventually died. Multivariate logistic regression analysis revealed that only mean night-time DBP (hazard ratio (HR): 1.04; 95% confidence interval (CI): 1.00-1.07) was an independent prognostic factor of death. Of the 175 patients without prior disability, 79 (45.1%) finally met the end-point of unfavourable functional outcome. Mean 24-h SBP (HR: 1.03; 95% CI: 1.00-1.05), day-time SBP (HR: 1.02; 95% CI: 1.00-1.05) and night-time SBP (HR: 1.03; 95% CI: 1.01-1.05), SBP nocturnal decline (HR: 0.93; 95% CI: 0.88-0.99), mean 24-h DBP (HR: 1.08; 95% CI: 1.03-1.13), day-time DBP (HR: 1.07; 95% CI: 1.03-1.12) and night-time DBP (HR: 1.06; 95% CI: 1.02-1.10) were independent prognostic factors of an unfavourable functional outcome. CONCLUSIONS In contrast with BPV indices, ABPM-derived BP levels and lower or absence of BP nocturnal decline in the acute phase are prognostic factors of outcome in AIS patients.
Collapse
Affiliation(s)
- Nikolaos Kakaletsis
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Medical School, University of Ioannina, University Hospital of Ioannina, Ioannina, Greece
| | - Anastasia Karagiannaki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Ioanna Chouvarda
- Laboratory of Medical Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Dourliou
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Achileas Chytas
- Laboratory of Medical Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos I Hatzitolios
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| |
Collapse
|
7
|
Impact of obstructive sleep apnea on cardiac organ damage in patients with acute ischemic stroke. J Hypertens 2019; 36:1351-1359. [PMID: 29570509 DOI: 10.1097/hjh.0000000000001697] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Both obstructive sleep apnea (OSA) and cardiac organ damage have a crucial role in acute ischemic stroke. Our aim is to explore the relationship between OSA and cardiac organ damage in acute stroke patients. METHODS A total of 130 consecutive patients with acute ischemic stroke were enrolled. Patients underwent full multichannel 24-h polysomnography for evaluation of OSA and echocardiography to evaluate left ventricle (LV) mass index (LV mass/BSA, LV mass/height), thickness of interventricular septum (IVS) and posterior wall (LVPW), LV ejection fraction and left atrium enlargement. Information on occurrence of arterial hypertension and its treatment before stroke was obtained from patients' history. RESULTS 61.9% (70) of patients, mostly men (67.1%), with acute stroke had OSA (AHI > 10). Patients with acute stroke and OSA showed a significant increase (P < 0.05) of LV mass index, IVS and LVPW thickness and a significant left atrial enlargement as compared with patients without OSA. LV ejection fraction was not significantly different in stroke patients with and without OSA and was within normal limits. No relationship was found among cardiac alterations, occurrence of OSA and history of hypertension. CONCLUSION Acute stroke patients with OSA had higher LV mass and showed greater left atrial enlargement than patients without OSA. This study confirms the high prevalence of OSA in stroke patients, suggesting also an association between OSA and cardiac target organ damage. Our finding of structural LV abnormalities in acute stroke patients with OSA suggests a potential role of OSA as contributing factor in determining both cerebrovascular and cardiac damage, even in absence of clear link with a history of blood pressure elevation.
Collapse
|
8
|
Sargento-Freitas J, Laranjinha I, Galego O, Rebelo-Ferreira A, Moura B, Correia M, Silva F, Machado C, Cordeiro G, Cunha L. Nocturnal blood pressure dipping in acute ischemic stroke. Acta Neurol Scand 2015; 132:323-8. [DOI: 10.1111/ane.12402] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2015] [Indexed: 11/29/2022]
Affiliation(s)
| | - I. Laranjinha
- Stroke Unit; Coimbra University and Hospital Centre; Coimbra Portugal
| | - O. Galego
- Stroke Unit; Coimbra University and Hospital Centre; Coimbra Portugal
| | - A. Rebelo-Ferreira
- Stroke Unit; Coimbra University and Hospital Centre; Coimbra Portugal
- Medical Oncology Department; Santa Maria Hospital - North Lisbon Hospital Centre; Lisbon Portugal
| | - B. Moura
- Stroke Unit; Coimbra University and Hospital Centre; Coimbra Portugal
- Psychiatry and Mental Health Department; Santa Maria Hospital - North Lisbon Hospital Centre; Lisbon Portugal
| | - M. Correia
- Stroke Unit; Coimbra University and Hospital Centre; Coimbra Portugal
- Paediatric Department; Dona Estefânia Hospital; Lisbon Portugal
| | - F. Silva
- Stroke Unit; Coimbra University and Hospital Centre; Coimbra Portugal
| | - C. Machado
- Stroke Unit; Coimbra University and Hospital Centre; Coimbra Portugal
| | - G. Cordeiro
- Stroke Unit; Coimbra University and Hospital Centre; Coimbra Portugal
| | - L. Cunha
- Stroke Unit; Coimbra University and Hospital Centre; Coimbra Portugal
| |
Collapse
|
9
|
De Raedt S, De Vos A, De Keyser J. Autonomic dysfunction in acute ischemic stroke: an underexplored therapeutic area? J Neurol Sci 2014; 348:24-34. [PMID: 25541326 DOI: 10.1016/j.jns.2014.12.007] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 11/30/2014] [Accepted: 12/02/2014] [Indexed: 01/04/2023]
Abstract
Impaired autonomic function, characterized by a predominance of sympathetic activity, is common in patients with acute ischemic stroke. This review describes methods to measure autonomic dysfunction in stroke patients. It summarizes a potential relationship between ischemic stroke-associated autonomic dysfunction and factors that have been associated with worse outcome, including cardiac complications, blood pressure variability changes, hyperglycemia, immune depression, sleep disordered breathing, thrombotic effects, and malignant edema. Involvement of the insular cortex has been suspected to play an important role in causing sympathovagal imbalance, but its exact role and that of other brain regions remain unclear. Although sympathetic overactivity in patients with ischemic stroke appears to be a negative prognostic factor, it remains to be seen whether therapeutic strategies that reduce sympathetic activity or increase parasympathetic activity might improve outcome.
Collapse
Affiliation(s)
- Sylvie De Raedt
- Department of Neurology, Universitair Ziekenhuis Brussel, Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Aurelie De Vos
- Department of Neurology, Universitair Ziekenhuis Brussel, Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Jacques De Keyser
- Department of Neurology, Universitair Ziekenhuis Brussel, Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Neurology, Universitair Medisch Centrum Groningen, Groningen, The Netherlands.
| |
Collapse
|
10
|
Zhang W, Cadilhac DA, Churilov L, Donnan GA, O’Callaghan C, Dewey HM. Does Abnormal Circadian Blood Pressure Pattern Really Matter in Patients With Transient Ischemic Attack or Minor Stroke? Stroke 2014; 45:865-7. [DOI: 10.1161/strokeaha.113.004058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- WenWen Zhang
- From the Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (W.Z., D.A.C., L.C., G.A.D., H.M.D.); Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia (D.A.C., L.C., G.A.D., C.O’C., H.M.D.); Translational Public Health Research Unit, Stroke and Ageing Research, Southern Clinical School, Monash University, Melbourne, Victoria, Australia (D.A.C.); Neurology Department, Austin Hospital, Heidelberg, Victoria, Australia (H.M.D.); Clinical Pharmacology,
| | - Dominique A. Cadilhac
- From the Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (W.Z., D.A.C., L.C., G.A.D., H.M.D.); Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia (D.A.C., L.C., G.A.D., C.O’C., H.M.D.); Translational Public Health Research Unit, Stroke and Ageing Research, Southern Clinical School, Monash University, Melbourne, Victoria, Australia (D.A.C.); Neurology Department, Austin Hospital, Heidelberg, Victoria, Australia (H.M.D.); Clinical Pharmacology,
| | - Leonid Churilov
- From the Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (W.Z., D.A.C., L.C., G.A.D., H.M.D.); Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia (D.A.C., L.C., G.A.D., C.O’C., H.M.D.); Translational Public Health Research Unit, Stroke and Ageing Research, Southern Clinical School, Monash University, Melbourne, Victoria, Australia (D.A.C.); Neurology Department, Austin Hospital, Heidelberg, Victoria, Australia (H.M.D.); Clinical Pharmacology,
| | - Geoffrey A. Donnan
- From the Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (W.Z., D.A.C., L.C., G.A.D., H.M.D.); Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia (D.A.C., L.C., G.A.D., C.O’C., H.M.D.); Translational Public Health Research Unit, Stroke and Ageing Research, Southern Clinical School, Monash University, Melbourne, Victoria, Australia (D.A.C.); Neurology Department, Austin Hospital, Heidelberg, Victoria, Australia (H.M.D.); Clinical Pharmacology,
| | - Christopher O’Callaghan
- From the Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (W.Z., D.A.C., L.C., G.A.D., H.M.D.); Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia (D.A.C., L.C., G.A.D., C.O’C., H.M.D.); Translational Public Health Research Unit, Stroke and Ageing Research, Southern Clinical School, Monash University, Melbourne, Victoria, Australia (D.A.C.); Neurology Department, Austin Hospital, Heidelberg, Victoria, Australia (H.M.D.); Clinical Pharmacology,
| | - Helen M. Dewey
- From the Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (W.Z., D.A.C., L.C., G.A.D., H.M.D.); Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia (D.A.C., L.C., G.A.D., C.O’C., H.M.D.); Translational Public Health Research Unit, Stroke and Ageing Research, Southern Clinical School, Monash University, Melbourne, Victoria, Australia (D.A.C.); Neurology Department, Austin Hospital, Heidelberg, Victoria, Australia (H.M.D.); Clinical Pharmacology,
| |
Collapse
|
11
|
Cerebral microbleeds are associated with nocturnal reverse dipping in hypertensive patients with ischemic stroke. BMC Neurol 2014; 14:8. [PMID: 24410771 PMCID: PMC3893541 DOI: 10.1186/1471-2377-14-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 01/03/2014] [Indexed: 11/21/2022] Open
Abstract
Background Abnormalities in nocturnal blood pressure dipping are well known for its relationship to cardiovascular diseases. Cerebral microbleeds are frequently observed in patients with hypertension and are known to be potent risk factors for stroke. However, there are scanty reports about the relationship between nocturnal dipping and cerebral microbleeds. Methods We recruited consecutive patients with both hypertension and ischemic stroke within 7 days after symptom onset, and those with cardioembolism were excluded. We applied 24-hour ambulatory blood pressure monitoring two weeks after stroke onset, and we used brain MRI to detect cerebral microbleeds. Various blood pressure parameters such as mean 24-hour blood pressure, awake/sleep blood pressure, and morning surge were compared between cerebral microbleeds (+) vs. (-) groups. Subjects were further classified according to nocturnal dipping status and were analyzed by logistic regression to determine its association with cerebral microbleeds with adjustment for age, gender, and cardiovascular risk factors. Results A total of 162 patients (100 males, age 65.33 ± 10.32 years) were included. Cerebral microbleeds were detected in 65 patients (40.1%). Most ambulatory blood pressure parameters except morning surge were significantly higher in those who had cerebral microbleeds. After adjusting for the confounding factors, the reverse dippers were prone to have cerebral microbleeds (odds ratio, 3.81; 95% confidential interval, 1.36-10.65; p-value = 0.01). Conclusion Cerebral microbleeds are independently associated with reverse dipping on ambulatory blood pressure monitoring in hypertensive stroke patients.
Collapse
|
12
|
Abstract
The purpose of this review is to highlight existing literature on the epidemiology, pathophysiology, and treatments of stroke sleep disorders. Stroke sleep disorders are associated with many intermediary vascular risk factors leading to stroke, but they may also influence these risk factors through direct or indirect mechanisms. Sleep disturbances may be further exacerbated by stroke or caused by stroke. Unrecognized and untreated sleep disorders may influence rehabilitation efforts and poor functional outcomes following stroke and increase risk for stroke recurrence. Increasing awareness and improving screening for sleep disorders is paramount in the primary and secondary prevention of stroke and in improving stroke outcomes. Many vital questions about the relationship of sleep disorders and stroke are still unanswered and await future well-designed studies.
Collapse
Affiliation(s)
- Douglas M Wallace
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | |
Collapse
|
13
|
Tsioufis C, Andrikou I, Thomopoulos C, Syrseloudis D, Stergiou G, Stefanadis C. Increased nighttime blood pressure or nondipping profile for prediction of cardiovascular outcomes. J Hum Hypertens 2010; 25:281-93. [DOI: 10.1038/jhh.2010.113] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
14
|
Ali K, Leong KMW, Houlder S, Getov S, Lee R, Rajkumar C. The relationship between dipping profile in blood pressure and neurologic deficit in early acute ischemic stroke. J Stroke Cerebrovasc Dis 2010; 20:10-15. [PMID: 20538485 DOI: 10.1016/j.jstrokecerebrovasdis.2009.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Revised: 09/15/2009] [Accepted: 09/21/2009] [Indexed: 11/18/2022] Open
Abstract
Blood pressure (BP) in healthy individuals exhibits a diurnal variation, with a nighttime dip of 10%-20%. A persistently high nighttime BP is associated with increased cardiovascular morbidity. The effects of diurnal BP variations on the neurologic deficit in acute stroke at presentation and in the first few weeks poststroke are unclear. We hypothesized that persistently elevated BP results in poor outcome. Patients with an acute ischemic stroke presenting within 48 hours of onset underwent 24-hour ambulatory monitoring of systolic, diastolic, and mean BP. There were a total of 35 patients (16 males; mean age, 74 ± 14 years). The percentage change between mean day and night BP classified patients into dippers (> 10% change), nondippers (0-10% change), or reverse-dippers (< 0% change). The Scandinavian Stroke Scale (SSS) and the National Institute of Health Stroke Scale (NIHSS) were assessed on admission, at week 1, and at week 3. The relationship between neurologic score and dipping classification was analyzed using analysis of variance and analysis of covariance, with age and baseline score as covariates. Based on both the SSS and NIHSS, the reverse-dippers had the lowest neurologic scores at baseline, week 1, and week 3, followed by the nondippers. The dippers performed the best in comparison. No significant differences in demographics and/or other BP characteristics among the groups that could account for these differences in outcome were noted. A reverse-dipping profile in diastolic BP was associated with poor neurologic state at baseline and weeks 1 and 3 compared with both dippers and nondippers.
Collapse
Affiliation(s)
- Khalid Ali
- Academic Department of Geriatrics, Brighton and Sussex Medical School, Brighton, UK.
| | | | | | - Spas Getov
- Brighton & Sussex University Hospitals Trust, Brighton, UK
| | - Richard Lee
- Brighton & Sussex University Hospitals Trust, Brighton, UK
| | | |
Collapse
|
15
|
Abstract
Transient ischemic attack is a medical emergency because early stroke risk after transient ischemic attack is high. Hypertension is the most important modifiable risk factor for stroke and transient ischemic attack. The aims of this review are to provide a summary of the current knowledge concerning the relationship between blood pressure and transient ischemic attack, as well as outline issues regarding diurnal variation and the potential of chronotherapy (timing medications to accord with diurnal patterns of blood pressure). There is a strong relationship between hypertension and the incidence of transient ischemic attack and the subsequent short-term risk for stroke. Ambulatory blood pressure monitoring is a reliable diagnostic and monitoring tool for hypertension and provides additional information about diurnal variation in blood pressure. Different diurnal blood pressure patterns may confer variable stroke risk. Patients with stroke commonly have abnormal diurnal blood pressure patterns and this may relate, in part, to autonomic nervous system dysfunction. However, blood pressure patterns have not been systematically studied in patients with transient ischemic attack. Blood pressure remains poorly controlled in a large proportion of patients after transient ischemic attack and under-treatment and poor adherence are important factors. Chronotherapy for blood pressure may result in more effective blood pressure control. More research is needed in this area. Hypertension is strongly associated with transient ischemic attack. Diurnal blood pressure patterns may influence subsequent stroke risk after transient ischemic attack and more evidence is needed to inform clinical practice to improve blood pressure management for transient ischemic attack patients.
Collapse
Affiliation(s)
- W W Zhang
- National Stroke Research Institute, part of Florey Neuroscience Institutes, Victoria, Australia
| | | | | | | | | |
Collapse
|
16
|
Micieli G, Cavallini A. The autonomic nervous system and ischemic stroke: a reciprocal interdependence. Clin Auton Res 2008; 18:308-17. [PMID: 18850312 DOI: 10.1007/s10286-008-0495-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 08/05/2008] [Indexed: 11/30/2022]
Abstract
Signs and symptoms of autonomic nervous system (ANS) dysfunction are frequently reported after ischemic or haemorrhagic stroke and in many cases they exhibit peculiar patterns in relationship with the site and the extension of brain lesion. However if an ANS disorder can cause or predispose to a stroke is far from being correctly known. Evidences in favor of a pathogenetic mechanism of an ANS dysfunction are reported for myocardial infarction and such data are likely to be appropriate also for atherothrombotic type of ischemic stroke. On the other hand, it is well known that many risk factors for this pathology are strongly correlated with an altered functioning of ANS so that a reciprocal interdependence between ANS and stroke can be hypothesized. This review points to evidence the possible relationship existing between these two conditions and suggests a quite different diagnostic and therapeutic approach to both on the basis of their pathogenetic mechanisms.
Collapse
Affiliation(s)
- Giuseppe Micieli
- Neurology and Stroke Unit, IRCCS Istituto Clinico Humanitas, Via Manzoni, 56, 20089, Rozzano, MI, Italy.
| | | |
Collapse
|
17
|
Wong AA, Read SJ. Early changes in physiological variables after stroke. Ann Indian Acad Neurol 2008; 11:207-20. [PMID: 19893676 PMCID: PMC2771993 DOI: 10.4103/0972-2327.44555] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 09/23/2008] [Accepted: 09/23/2008] [Indexed: 01/04/2023] Open
Abstract
Several aspects of physiology, notably blood pressure, body temperature, blood glucose, and blood oxygen saturation, may be altered after an ischemic stroke and intracerebral hemorrhage. Generally, blood pressure and temperature rise acutely after a stroke, before returning to normal. Blood glucose and oxygen levels may be abnormal in individuals, but they do not follow a set pattern. Several aspects of these physiological alterations remain unclear, including their principal determinants - whether they genuinely affect prognosis (as opposed to merely representing underlying processes such as inflammation or a stress response), whether these effects are adaptive or maladaptive, whether the effects are specific to certain subgroups (e.g. lacunar stroke) and whether modifying physiology also modifies its prognostic effect. Hypertension and hyperglycemia may be helpful or harmful, depending on the perfusion status after an ischemic stroke; the therapeutic response to their lowering may be correspondingly variable. Hypothermia may provide benefits, in addition to preventing harm through protection from hyperthermia. Hypoxia is harmful, but normobaric hyperoxia is unhelpful or even harmful in normoxic patients. Hyperbaric hyperoxia, however, may be beneficial, though this remains unproven. The above-mentioned uncertainties necessitate generally conservative measures for physiology management, although there are notably specific recommendations for thrombolysis-eligible patients. Stroke unit care is associated with better outcome, possibly through better management of poststroke physiology. Stroke units can also facilitate research to clarify the relationship between physiology and prognosis, and to subsequently clarify management guidelines.
Collapse
Affiliation(s)
- Andrew A Wong
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia. Central Clinical School, School of Medicine, University of Queensland, Brisbane, Queensland, Australia.
| | | |
Collapse
|
18
|
Hajjar I, Selim M, Novak P, Novak V. The relationship between nighttime dipping in blood pressure and cerebral hemodynamics in nonstroke patients. J Clin Hypertens (Greenwich) 2008; 9:929-36. [PMID: 18046099 DOI: 10.1111/j.1524-6175.2007.07342.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Inadequate dipping in nighttime blood pressure (BP) is associated with cerebrovascular disease. The authors aimed to determine whether inadequate nocturnal dipping was associated with abnormalities in cerebrovascular hemodynamics in individuals without stroke. Participants in this study underwent 24-hour ambulatory BP monitoring followed by morning transcranial Doppler measurements of blood flow velocities (BFVs) in the middle cerebral artery during supine rest, head-up tilt, hypocapnia, and hypercapnia. Nighttime BP decline by <10% was considered nondipping. Of the 102 nonstroke participants (mean age, 53.6 years), 35 (34%) were dippers. Although nondippers had similar BFV and cerebrovascular resistance (CVR) while supine, they had a lower BFV (P=.04) and greater CVR (P=.02) during head-up tilt compared with dippers. Moreover, greater nighttime dipping in both systolic BP (P=.006) and diastolic BP (P=.03) were associated with higher daytime BFV and lower CVR (P=.01 for systolic BP; P=.02 for diastolic BP). Inadequate nocturnal BP dipping is associated with lower daytime cerebral blood flow, especially during head-up tilt.
Collapse
Affiliation(s)
- Ihab Hajjar
- Beth Israel Deaconess Medical Center, Institute for Aging Research at Hebrew SeniorLife, Boston, MA 02131, USA.
| | | | | | | |
Collapse
|
19
|
Fuentes B, Díez-Tejedor E. General Care in Stroke: Relevance of Glycemia and Blood Pressure Levels. Cerebrovasc Dis 2007; 24 Suppl 1:134-42. [DOI: 10.1159/000107389] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
|