1
|
Liang F, Yin Z, Li Y, Li G, Ma J, Zhang H, Xia X, Yao M, Pang X, Wang J, Chang X, Guo J, Zhang W. Constructing and Validating a Nomogram Model for Short-Term Prognosis of Patients with AChR-Ab+ GMG. Neurol Ther 2024; 13:551-562. [PMID: 38427273 PMCID: PMC11136915 DOI: 10.1007/s40120-024-00590-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE This study aimed to establish and validate a nomogram prognostic model for predicting short-term efficacy of acetylcholine receptor antibody-positive (AChR-Ab+) generalized myasthenia gravis (GMG). METHODS A retrospective observational study was conducted at the First Hospital of Shanxi Medical University, enrolling patients diagnosed with AChR-Ab+ GMG from May 2020 to September 2022. The primary outcome was the change in the Myasthenia Gravis Foundation of America (MGFA) post-intervention status after 6 months of standard treatment. Predictive factors were identified through univariate and multivariate logistic regression analyses, with significant factors incorporated into the nomogram. The bootstrap test was used for internal validation of the nomogram model. Model performance was assessed using calibration curves, receiver-operating characteristic curve analysis, and decision curve analysis (DCA). RESULTS A total of 90 patients were enrolled, of whom 30 achieved unchanged or worse status after 6 months of standard therapy. Univariate logistic regression analysis showed that quantitative myasthenia gravis score, gender, body mass index, course of disease, hemoglobin levels, and white blood cell counts were six potential predictors. These factors were used for multivariate logistic regression analysis, and a nomogram was constructed. The calibration curve showed that the predicted value was in good agreement with the actual value (p = 0.707), and the area under the curve value (0.792, 95% CI 0.686-0.899) indicated good discrimination ability. DCA suggests that this model has potential clinical application value. CONCLUSION The constructed nomogram, based on key patient indicators, shows promise as a clinically useful tool for predicting the short-term efficacy of treatment of AChR-Ab+ GMG. Validation in larger, multicenter cohorts is needed to further substantiate its applicability.
Collapse
Affiliation(s)
- Feng Liang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Zhaoxu Yin
- Department of Neurology, Taiyuan City Central Hospital, Taiyuan, China
| | - Yaqian Li
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Guanxi Li
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Jing Ma
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Huiqiu Zhang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Xiaoqian Xia
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Make Yao
- Shanxi Medical University, Taiyuan, China
| | - Xiaomin Pang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
| | - Juan Wang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
| | - Xueli Chang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
| | - Junhong Guo
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
| | - Wei Zhang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China.
| |
Collapse
|
2
|
Ma K, Bebawy JF. Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature. Anesth Analg 2024; 138:992-1002. [PMID: 38109853 DOI: 10.1213/ane.0000000000006772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.
Collapse
Affiliation(s)
- Kan Ma
- From the Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
3
|
Wang T, Zhong W, Chen Z, Shen K, Ye H, Yu Z, Luo J, Ma J, Lou M. Association between baseline hemoglobin level and early neurological deterioration after intravenous thrombolysis in patients with acute ischemic stroke. Zhejiang Da Xue Xue Bao Yi Xue Ban 2024; 53:168-174. [PMID: 38501300 PMCID: PMC11057983 DOI: 10.3724/zdxbyxb-2023-0510] [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: 10/29/2023] [Accepted: 03/01/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To investigate the association between baseline hemoglobin level and early neurologic deterioration (END) after intravenous thrombolysis in patients with acute ischemic stroke (AIS). METHODS Data of AIS patients who received intravenous thrombolytic therapy at multiple hospitals across the country between January 2017 and July 2020 were collected from the online database Acute Stroke Patients for Stroke Management Quality Evaluation (CASE-Ⅱ, NCT04487340). Binary logistic regression analysis was used to study the factors affecting the occurrence of END after intravenous thrombolytic therapy, and the correlation between baseline hemoglobin level and END was investigated by limiting cubic spline curve analysis. RESULTS A total of 8162 patients were included. Patients with END had lower baseline hemoglobin levels (136 and 140 g/L, P<0.01) and higher rates of anemia (24.2% and 16.9%, P<0.01) compared with non-END patients. Binary logistic regression analysis showed that baseline hemoglobin level (OR=0.995, 95%CI: 0.991-0.999, P<0.05) and anemia (OR=1.238, 95%CI: 1.055-1.454, P<0.01) were independently correlated with the occurrence of END after intravenous thrombolysis in AIS patients. Restricted cubic spline regression showed that there was a U-shaped relationship between hemoglobin level and the risk of END after intravenous thrombolysis in AIS patients (P<0.01), although this relationship was only significant in male patients (P<0.05) and not in female patients (P>0.05). CONCLUSIONS There is a correlation between baseline hemoglobin level and the risk of END in AIS patients after intravenous thrombolysis, especially in male patients, in whom both lower and higher hemoglobin level may increase the risk of END.
Collapse
Affiliation(s)
- Tinghuan Wang
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
- Department of Neurology, the First People's Hospital of Jiashan County, Jiaxing 314100, Zhejiang Province, China.
| | - Wansi Zhong
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhicai Chen
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Ke Shen
- Department of Neurology, Shaoxing Hospital Affiliated to China Medical University, Shaoxing 312099, Zhejiang Province, China
| | - Huiya Ye
- Department of Neurology, Shaoxing Hospital Affiliated to China Medical University, Shaoxing 312099, Zhejiang Province, China
| | - Zhihui Yu
- Department of Neurology, Shaoxing Hospital Affiliated to China Medical University, Shaoxing 312099, Zhejiang Province, China
| | - Jia Luo
- Department of Neurology, Shaoxing Hospital Affiliated to China Medical University, Shaoxing 312099, Zhejiang Province, China
| | - Jun Ma
- Department of Neurology, Shaoxing Hospital Affiliated to China Medical University, Shaoxing 312099, Zhejiang Province, China
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
| |
Collapse
|
4
|
Ceulemans A, Pinckaers FM, Postma AA, van Zwam WH, van Oostenbrugge RJ. Association Between Anemia and Clinical Outcome in Acute Ischemic Stroke Patients Treated With Endovascular Treatment. J Stroke 2024; 26:87-94. [PMID: 38246723 PMCID: PMC10850445 DOI: 10.5853/jos.2023.01669] [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: 05/21/2023] [Revised: 09/14/2023] [Accepted: 10/20/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND AND PURPOSE Endovascular treatment (EVT) is the preferred treatment option in eligible acute ischemic stroke (AIS) patients with a large vessel occlusion of the anterior circulation. Several comorbidities have been identified that can affect clinical outcomes. Various studies have investigated the association between anemia and clinical outcome and found conflicting. RESULTS . The aim is to investigate the association between pre-EVT anemia and clinical outcomes at different time points post-EVT, primarily focusing on the National Institutes of Health Stroke Scale (NIHSS) at 24-48 hours. METHODS We prospectively included 560 AIS patients who received EVT in the Maastricht University Medical Center+. Hemoglobin levels (Hb; g/dL) were determined on admission. Hb levels were also categorized into two groups: anemia (male: Hb ≤12.9 g/dL; female: Hb ≤11.9 g/dL) and no anemia. Multiple imputation was used to handle missing data. Multivariable regression was used to investigate the association between anemia or Hb levels and clinical outcomes. RESULTS Anemia was present in 26% of the patients. Multivariable regression did not show a significant association between anemia or Hb levels and NIHSS at 24-48 hours (adjusted β [aβ]anemia: 1.44, 95% confidence interval [CI]: -0.47 to 3.36; aβHb: -0.37, 95% CI: -0.88 to 0.13). However, multivariable regression showed significant associations with modified Rankin Scale (adjusted common odds ratio [acOR]anemia: 1.66, 95% CI: 1.12 to 2.48; acORHb: 0.83, 95% CI: 0.75 to 0.93) and poor functional outcome at 90 days (adjusted OR [aOR]anemia: 2.09, 95% CI: 1.21 to 3.63; aORHb: 0.80, 95% CI: 0.69 to 0.92). CONCLUSION Anemia was not independently associated with early neurological deficit (NIHSS) post-AIS, suggesting it is more suitable as a general frailty marker.
Collapse
Affiliation(s)
- Angelique Ceulemans
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Florentina M.E. Pinckaers
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Alida A. Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
| | - Wim H. van Zwam
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Robert J. van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center+, Maastricht, The Netherlands
| |
Collapse
|
5
|
Nisar T, Tofade T, Lebioda K, Shaulov S, Shapouran S, Abu-Hadid O, Khandelwal P. Association of blood pressure parameters post mechanical thrombectomy in anemic versus non-anemic patients and clinical outcomes. J Clin Neurosci 2023; 118:153-160. [PMID: 37944359 DOI: 10.1016/j.jocn.2023.11.002] [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: 06/01/2023] [Revised: 09/30/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Higher blood pressure (BP) is considered to be detrimental in patients who undergo mechanical thrombectomy (MT), however, the impact of BP post-MT based on comorbidities like anemia has not been well studied. We aim to determine the association of 24-h post-MT BP parameters with clinical outcomes depending on their anemia status. METHODS We conducted a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 1/2015 to 12/2020. Patients were dichotomized into anemic and non-anemic groups based on the World Health Organization's definition of anemia [hemoglobin < 12.0 g/dL in women and < 13.0 g/dL in men]. We performed a multivariable analysis with binary logistic regression with the 24-h post-MT BP parameters as predictors. The outcomes were functional dependence (3-month mRS 3-6), mortality, and an early neurological improvement. RESULTS 220 patients met the inclusion criteria. 158 (71.82 %) patients had functional dependence at 3-months. In the multivariable analysis, the parameters of a higher mean SBP (132.9 ± 11.94 vs.126.52 ± 13.3; OR, 1.05; 95 % CI, 1.02-1.09; P 0.011), a higher mean MAP (93.35 ± 8.44 vs.89.69 ± 10.03; OR,1.06; 95 % CI, 1.01-1.11; P 0.029) and a higher maximum MAP (115.26 ± 11.73 vs.109.37 ± 12.51; OR,1.05; 95 % CI, 1.01-1.08; P 0.023)were significantly associated with functional dependence in non-anemic patients, while a lower mean DBP (65.53 ± 9.73 vs. 71.94 ± 10.16; OR, 0.92; 95 % CI, 0.86-0.98; P 0.007), lower mean MAP (85.7 ± 8.65 vs. 91.38 ± 10; OR, 0.93; 95 % CI, 0.86-0.99; P 0.02), a lower minimum DBP (49.27 ± 10.51 vs. 55.1 ± 11.23; OR, 0.93; 95 % CI, 0.88-0.99; P 0.019), a lower minimum MAP (68.96 ± 9.54 vs. 74.73 ± 10.47; OR, 0.93; 95 % CI, 0.87-0.99; P 0.023) were significantly associated with mortality in patients with anemia, and a lower minimum DBP (54.75 ± 10.42 vs. 59.69 ± 8.87; OR, 0.95; 95 % CI, 0.91-0.99; P 0.012) and a lower minimum MAP (71.92 ± 14.7 vs.75.67 ± 14.17; OR, 0.97; 95 % CI, 0.94-0.99; P 0.047) were significantly associated with an early neurological improvement in non-anemic patients. For patients with anemia, there was no association between 24-hour BP Parameters post-MT and functional dependence and early neurological improvement, and between 24-hour BP Parameters post-MT and mortality in non-anemic patients. CONCLUSION In our study, higher BP parameters were associated with worse outcomes in patients without anemia, however, this effect was not found in patients with anemia. Certain lower BP parameters were associated with higher 3-month mortality in anemic patients; however, this effect was not found in non-anemic patients. Higher BP post-MT can potentially promote perfusion and thus is not associated with worse outcomes in anemic patients post-MT, whereas in non-anemic patients it may potentially lead to reperfusion injury While our study is limited because of size and its retrospective nature, the findings suggest that an individualized approach to tailor the target BP post-MT to a patient's risk factor profile and associated co-morbid conditions to achieve optimization of medical care post-MT and associated co-morbid conditions to achieve optimization of medical care post-MT.
Collapse
Affiliation(s)
- Taha Nisar
- University of South Alabama, Mobile, AL, USA.
| | | | | | | | | | | | | |
Collapse
|
6
|
Qiu S, Liao J, Luo X, Chen X. Prognostic Value of the Neutrophil-to-Lymphocyte Ratio in Older Patients with Acute Ischemic Stroke. J NIPPON MED SCH 2023; 90:58-63. [PMID: 36908129 DOI: 10.1272/jnms.jnms.2023_90-110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2023]
Abstract
BACKGROUND The prognostic value of the neutrophil-to-lymphocyte ratio (NLR), an inflammatory indicator, for 90-day outcomes has not been determined for patients with acute ischemic stroke aged ≥ 80 years. Therefore, this study examined the predictive significance of the NLR for estimating the 90-day outcomes of older patients with acute ischemic stroke. METHODS Data from patients aged ≥ 80 years were recorded within 7 days of ischemic stroke onset during the period from January 2019 to June 2021. A Kaplan-Meier curve was drawn based on the incidence of adverse outcomes to compare the survival probability of each group at different time periods. Cox multivariate regression was used to explore adverse events affecting patient prognosis. RESULTS A total of 560 patients were initially recruited; of these, 476 were eligible for inclusion. The log-rank test showed that the survival rates of the groups differed. The 90-day survival rate was significantly lower in the group with the highest NLR than in the group with the lowest NLR. Multivariate Cox regression analysis showed that after adjusting for risk factors, a high NLR and a high National Institutes of Health Stroke Scale score were independent risk factors for 90-day mortality. According to the receiver operating characteristic analysis, the area under the curve for predicting mortality at 90 days was 0.74. CONCLUSION This study confirmed that a high NLR is an independent risk factor for acute ischemic stroke and has predictive value for 90-day prognosis in patients aged ≥ 80 years.
Collapse
Affiliation(s)
- Shuang Qiu
- Department of Neurology, Affiliated Hospital of Southwest Medical University
| | - Jie Liao
- Department of Neurology, Affiliated Hospital of Southwest Medical University
| | - Xin Luo
- Department of Neurology, Affiliated Hospital of Southwest Medical University
| | - Xiu Chen
- Department of Neurology, Affiliated Hospital of Southwest Medical University
| |
Collapse
|
7
|
Nisar T, Lebioda K, Shaulov S, Shapouran S, Abu-Hadid O, Tofade T, Khandelwal P. Interplay between anemia parameters and collateral status in patients who undergo mechanical thrombectomy. J Clin Neurosci 2022; 104:34-41. [PMID: 35944336 DOI: 10.1016/j.jocn.2022.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/07/2022] [Accepted: 07/25/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Anemia is associated with higher morbidity and mortality, but its association with acute ischemic stroke (AIS) is not well established. We aim to determine the association of five-day anemia parameters with clinical outcomes in patients with an AIS, depending on their pre-mechanical thrombectomy (MT) collateral status. METHODS We performed a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 7/2014 to 12/2020. The patients were divided into good and poor collateral groups depending on their pre-MT collateral status. A blinded board-certified neuroradiologist used collateral grading scale of Maas ≥ 3 to designate good collaterals on the pre-MT CT Angiogram. A binary logistic regression analysis was performed, controlling for the baseline parameters, with the five-day anemia parameters as predictors. The outcomes were functional independence (mRS 0-2), mortality, and early neurological improvement. RESULTS A total of 220 met the inclusion criteria. 94 (42.72 %) patients had good collaterals, while 126 (57.27 %) patients had poor collaterals. In the multivariable analysis, for patients with good collaterals, the higher values of five-day mean Hb (12.41 ± 1.87 vs 11.32 ± 1.95; OR, 0.72; 95 % CI, 0.54-0.95; P 0.018), five-day mean HCT (37.43 ± 5.1 vs 34.35 ± 5.5; OR, 0.89; 95 % CI, 0.81-0.98; P 0.018) and lower values of the difference between peak and trough values of Hb (1.75 ± 1.15 vs 2.41 ± 1.35; OR, 1.71; 95 % CI, 1.07-2.74; P 0.025) were associated with functional independence. For patients with poor collaterals, there was no association between five-day mean Hb, mean HCT parameters with functional independence, lower mortality, and early neurological improvement. CONCLUSION Our study was suggestive of an association between higher mean values of Hb and HCT over a five-day period and good clinical outcomes in patients with good collaterals who undergo MT for an anterior circulation LVO. This association was not found in the poor collateral group.
Collapse
Affiliation(s)
- Taha Nisar
- University of South Alabama, Mobile, AL, USA.
| | | | | | | | | | - Toluwalase Tofade
- Rutgers New Jersey Medical School, Newark, NJ, USA; Montefiore Medical Center, The Bronx, NY, USA
| | | |
Collapse
|
8
|
The association between fatigue severity and risk of falls among middle-aged and older Australian stroke survivors. Aging Clin Exp Res 2022; 34:2457-2463. [PMID: 35796976 PMCID: PMC9637598 DOI: 10.1007/s40520-022-02179-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/08/2022] [Indexed: 12/03/2022]
Abstract
Background Fatigue is a common and often debilitating symptom experienced by many stroke survivors. Significant post stroke fatigue may predispose individuals to other health complications, such as falls, which can lead to fractures and soft tissue injuries. Only limited research has examined the association between fatigue and falls in stroke survivors. Methods Data were obtained from the Sax Institute’s 45 and Up Study, from a subset of individuals who had experienced a stroke. The Modified Fatigue Impact Scale—5-item version (MFIS-5) was used to measure the level of fatigue. A logistic regression model, adjusted for stroke characteristics and comorbidities, was used to determine the magnitude of association between change in fatigue score and odds of having had a fall. Results A total of 576 participants completed the questionnaire. A total of 214 (37.2%) participants reported having had a fall in the previous 12 months. There was a statistically significant association between fatigue scores and fall status (p < 0.001). Specifically, for every 1-point increase in the fatigue score (MFIS-5) (i.e. higher level of fatigue), the odds of a person having a fall is 1.10 times greater (AOR = 1.10; 95% CI 1.05, 1.15; p < 0.001). Conclusion This study revealed an association between an increasing risk of falls with increasing severity of post stroke fatigue. Accurate detection and management of fatigue may help reduce the risk of falls and should be the focus of future research.
Collapse
|
9
|
Relationship between baseline haemoglobin content and poststroke cognitive impairment. J Clin Neurosci 2022; 101:212-216. [DOI: 10.1016/j.jocn.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/22/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
|
10
|
Tao X, Zhou H, Mo D, Zhang W, Chang Z, Zeng Y, Luo Y, Wu S, Tang W, Yang C, Wang Q. Erythrocytes Are an Independent Protective Factor for Vascular Cognitive Impairment in Patients With Severe White Matter Hyperintensities. Front Aging Neurosci 2022; 14:789602. [PMID: 35250538 PMCID: PMC8894857 DOI: 10.3389/fnagi.2022.789602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Hemoglobin is one of the main proteins in erythrocytes. There are significant correlations between low hemoglobin and white matter hyperintensities (WMH) and cognitive impairment. This study explored whether erythrocytopenia has predictive value for vascular cognitive impairment (VCI) in patients with WMH. Method: We conducted a cross-sectional study of 302 patients, including 62 with cerebral small vessel disease and 240 with stroke. Basic demographic data and fasting blood were collected. First, all patients were divided into normal cognition (NC), mild VCI (mVCI), and severe VCI (sVCI) groups (subgroups later) based on cognitive behavior scores. Second, all patients were divided into mild WMH (mWMH) and severe WMH (sWMH) groups based on Fazekas scores. The differences in blood markers between different groups or subgroups with different cognitive levels were analyzed by univariate analysis. Then, binary logistic regression was used to analyze the diagnostic value of erythrocyte counts for VCI in the sWMH group, and ordinal logistic regression was used to analyze the predictive value of multiple variables for different cognitive levels. Results: Univariate analysis showed that erythrocytes, hemoglobin, high-sensitivity C-reactive protein, retinol binding protein and prealbumin were potential blood markers for different cognitive levels in sWMH patients. Among them, erythrocytopenia has good predictive value for the diagnosis of mVCI (AUC = 0.685, P = 0.008) or sVCI (AUC = 0.699, P = 0.003) in patients with sWMH. Multivariate joint analysis showed that erythrocytes were an independent protective factor reducing the occurrence of VCI in patients with sWMH (OR = 0.633, P = 0.045). Even after adjusting for age, there was still a significant difference (P = 0.047). Conclusion: Erythrocytes are an independent protective factor for VCI in patients with sWMH. Promoting hematopoietic function may have potential value for prevention of cognitive decline in patients with cerebrovascular disease.
Collapse
Affiliation(s)
- Xi Tao
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Department of Neurological Rehabilitation, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Hang Zhou
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Danheng Mo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Department of Neurological Rehabilitation, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Wenjie Zhang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zihan Chang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yiheng Zeng
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yuqi Luo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Siyuan Wu
- Department of Neurological Rehabilitation, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Wenjing Tang
- Department of Neurological Rehabilitation, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Chen Yang
- Department of Neurological Rehabilitation, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Qing Wang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- *Correspondence: Qing Wang
| |
Collapse
|
11
|
Liu Y, Zhao J, Li F, Sun H, Sun Y, Sun H, Yang F, Zhao Y, Liang Z, Tang Y. Predictive value of hemoglobin level on early neurological outcomes in acute ischemic stroke. Neurol Res 2022; 44:684-691. [PMID: 35130819 DOI: 10.1080/01616412.2022.2035621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Few studies have examined the association between hemoglobin (Hb) levels and early neurological changes following acute ischemic stroke (AIS). The present research investigated whether higher or lower Hb level on admission was associated with early neurological deterioration (END) in AIS patients. Furthermore, we evaluated the predictive effect of Hb concentration on stable or improving outcome. METHODS In this prospective cohort study, a total of 1330 patients admitted within 24 hours after AIS onset were finally involved in the analysis. We classified participants into four groups according to baseline Hb levels: ≤120, 121-140, 141-160, and >160 g/L. The risk of END was accessed by means of logistic regression analysis, and tendency of improvement and stability by multinomial logit analysis. We further evaluated the pattern and magnitude of association of Hb as a continuous variable and END by multivariate logistic regression analysis of restricted cubic spline. RESULTS Compared with the reference group, hemoglobin >160 g/L was associated with END (OR, 95%CI; 2.149, 1.314-3.512) and severe END (OR, 95% CI as 2.317, 1.351-3.976 and 2.810,1.589-4.968, respectively). Comparatively, higher Hb level also independently predicted improving (OR, 95% CI; 0.322, 0.170-0.609) and stable (OR, 95% CI; 0.371, 0.205-0.673) outcome. Similar results were found when restricted to anterior circulation ischemic stroke after adjustment of variables including large vessel disease. CONCLUSIONS We concluded that patients with higher baseline Hb level are at significantly higher risk for END, and less likely to reach stable or improving status at the early stage of stroke.
Collapse
Affiliation(s)
- Yue Liu
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Jingbo Zhao
- Department of Epidemiology, School of Public Health, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Fang Li
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Hongwei Sun
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yanyan Sun
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Hongwei Sun
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Fan Yang
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yu Zhao
- Department of Laboratory Diagnosis, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Zijun Liang
- Department of Health Insurance Management, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Ying Tang
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| |
Collapse
|
12
|
Association of anemia with functional outcomes in patients with mechanical thrombectomy. Clin Neurol Neurosurg 2021; 211:107028. [PMID: 34826754 DOI: 10.1016/j.clineuro.2021.107028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/31/2021] [Accepted: 11/05/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Anemia at presentation is associated with worse outcomes in patients with acute ischemic stroke (AIS). We aim to investigate the association of anemia parameters with functional dependence and mortality in patients who undergo mechanical thrombectomy (MT). METHODS We performed a retrospective chart review of patients who underwent MT for an anterior circulation large vessel occlusion at a comprehensive stroke center from 1/2015-6/2020. Anemia was considered as a dichotomous categorical variable with a cutoff point of hemoglobin (Hb) < 12.0 g/dL in women and < 13.0 g/dL in men, as per the definition of the World Health Organization. Mean values of Hb and hematocrit (HCT) were obtained over the first five days of admission. Hemoglobin and HCT variability were measured using standard deviation (SD), and coefficient variability (CV) over the first five days of admission. Values of variance and difference (the difference between peak and trough of Hemoglobin or HCT) were also recorded. Multivariate logistic regression analyses were performed, including the predictor variables which were contributing significantly to the model (P < 0.05) in the univariate analysis, with 30-day functional dependence (mRS 3-6) (primary outcome) and 30-day mortality (secondary outcome) as the dependent variables. RESULTS 188 patients met our inclusion criteria. Anemia on presentation, lower mean and minimum values of five-day Hb and HCT, and higher variability in five-day Hb and HCT parameters were associated with higher 3-month mortality. Men with lower mean and minimum values of five-day Hb and HCT had a significantly higher likelihood of functional dependence at 3-months. This finding was not replicated amongst women in our cohort. CONCLUSION Our study demonstrated higher 3-mortality in patients with anemia and Hb variability. Our study also demonstrated a higher likelihood of functional dependence in patients amongst men with anemia.
Collapse
|
13
|
Ganesh A, Ospel JM, Menon BK, Demchuk AM, McTaggart RA, Nogueira RG, Poppe AY, Almekhlafi MA, Hanel RA, Thomalla G, Holmin S, Puetz V, van Adel BA, Tarpley JW, Tymianski M, Hill MD, Goyal M. Assessment of Discrepancies Between Follow-up Infarct Volume and 90-Day Outcomes Among Patients With Ischemic Stroke Who Received Endovascular Therapy. JAMA Netw Open 2021; 4:e2132376. [PMID: 34739060 PMCID: PMC8571657 DOI: 10.1001/jamanetworkopen.2021.32376] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
IMPORTANCE Some patients have poor outcomes despite small infarcts after endovascular therapy (EVT), while others with large infarcts do well. Understanding why these discrepancies occur may help to optimize EVT outcomes. OBJECTIVE To validate exploratory findings from the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial regarding pretreatment, treatment-related, and posttreatment factors associated with discrepancies between follow-up infarct volume (FIV) and 90-day functional outcome. DESIGN, SETTING, AND PARTICIPANTS This cohort study is a post hoc analysis of the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, a double-blind, randomized, placebo-controlled, international, multicenter trial conducted from March 2017 to August 2019. Patients who participated in ESCAPE-NA1 and had available 90-day modified Rankin Scale (mRS) scores and 24-hour to 48-hour posttreatment follow-up parenchymal imaging were included. EXPOSURES Small FIV (volume ≤25th percentile) and large FIV (volume ≥75th percentile) on 24-hour computed tomography/magnetic resonance imaging. Baseline factors, outcomes, treatments, and poststroke serious adverse events (SAEs) were compared between discrepant cases (ie, patients with 90-day mRS score ≥3 despite small FIV or those with mRS scores ≤2 despite large FIV) and nondiscrepant cases. MAIN OUTCOMES AND MEASURES Area under the curve (AUC) and goodness of fit of prespecified logistic models, including pretreatment (eg, age, cancer, vascular risk factors) and treatment-related and posttreatment (eg, SAEs) factors, were compared with stepwise regression-derived models for ability to identify small FIV with higher mRS score and large FIV with lower mRS score. RESULTS Among 1091 patients (median [IQR] age, 70.8 [60.8-79.8] years; 549 [49.7%] women; median [IQR] FIV, 24.9 mL [6.6-92.2 mL]), 42 of 287 patients (14.6%) with FIV of 7 mL or less (ie, ≤25th percentile) had an mRS score of at least 3; 65 of 275 patients (23.6%) with FIV of 92 mL or greater (ie, ≥75th percentile) had an mRS score of 2 or less. Prespecified models of pretreatment factors (ie, age, cancer, vascular risk factors) associated with low FIV and higher mRS score performed similarly to models selected by stepwise regression (AUC, 0.92 [95% CI, 0.89-0.95] vs 0.93 [95% CI, 0.90-0.95]; P = .42). SAEs, specifically infarct in new territory, recurrent stroke, pneumonia, and congestive heart failure, were associated with low FIV and higher mRS scores; stepwise models also identified 24-hour hemoglobin as treatment-related/posttreatment factor (AUC, 0.92 [95% CI, 0.90-0.95] vs 0.94 [95% CI, 0.91-0.96]; P = .14). Younger age was associated with high FIV and lower mRS score; stepwise models identified absence of diabetes and higher baseline hemoglobin as additional pretreatment factors (AUC, 0.76 [95% CI, 0.70-0.82] vs 0.77 [95% CI, 0.71-0.83]; P = .82). Absence of SAEs, especially stroke progression, symptomatic intracerebral hemorrhage, and pneumonia, was associated with high FIV and lower mRS score2; stepwise models also identified 24-hour hemoglobin level, glucose, and diastolic blood pressure as posttreatment factors associated with discrepant cases (AUC, 0.80 [95% CI, 0.74-0.87] vs 0.79 [95% CI, 0.72-0.86]; P = .92). CONCLUSIONS AND RELEVANCE In this study, discrepancies between functional outcome and post-EVT infarct volume were associated with differences in pretreatment factors, such as age and comorbidities, and posttreatment complications related to index stroke evolution, secondary prevention, and quality of stroke unit care. Besides preventing such complications, optimization of blood pressure, glucose levels, and hemoglobin levels are potentially modifiable factors meriting further study.
Collapse
Affiliation(s)
- Aravind Ganesh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Johanna M. Ospel
- Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bijoy K. Menon
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ryan A. McTaggart
- Departments of Diagnostic Imaging, Neurology, and Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Raul G. Nogueira
- Departments of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine, Atlanta, Georgia
- Neuroendovascular Service, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Alexandre Y. Poppe
- Department of Neurosciences, Centre Hospitalier de l’Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - Mohammed A. Almekhlafi
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Götz Thomalla
- Departments of Neurology and Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Departments of Neuroradiology and Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Volker Puetz
- Dresden Neurovascular Center, Department of Neurology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | | | - Jason W. Tarpley
- Providence Little Company of Mary Medical Center, Providence Saint John’s Health Center and The Pacific Neuroscience Institute, Torrance, California
| | - Michael Tymianski
- Division of Neurosurgery and Neurovascular Therapeutics Program, University Health Network, Departments of Surgery and Physiology, University of Toronto, Toronto Western Hospital Research Institute, Toronto, Canada
- NoNO Inc, Toronto, Ontario, Canada
| | - Michael D. Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
14
|
Hsu CW, Chen NC, Huang WC, Lin HC, Tsai WC, Huang CC, Cheng BC, Tsai NW. Hemogram parameters can predict in-hospital mortality of patients with Myasthenic crisis. BMC Neurol 2021; 21:388. [PMID: 34615473 PMCID: PMC8493047 DOI: 10.1186/s12883-021-02412-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/23/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disease involving the neuromuscular junction. Myasthenic crisis (MC), which is characterized by respiratory failure and the requirement of mechanical ventilation in patients with MG, is still a medical emergency despite the decrease in mortality with the advances in acute management. Hemogram is a cost-effective test for evaluating hematological complications and systemic inflammation, and hemogram data have been used to predict various clinical outcomes of several diseases. The relationship between hemogram and MG has been discussed, but the role of hemogram data in predicting the prognosis of MC patients has not been established. METHODS To identify whether hemogram data can predict in-hospital mortality in patients with MC, we retrospectively investigated 188 myasthenic crisis events from the Chang Gung Research Database between April 2001 and March 2019. Demographic and clinical characteristics were collected, as well as hemogram data before intubation and extubation. The endpoints were mortality during mechanical ventilation and mortality after extubation. RESULTS The overall in-hospital mortality rate was 22%. Multivariate logistic regression analysis for predicting mortality during mechanical ventilation showed that old age at MC onset (OR = 1.039, p = 0.022), moderate-to-severe anemia (OR = 5.851, p = 0.001), and extreme leukocytosis (OR = 5.659, p = 0.022) before intubation were strong predictors of mortality, while acute management with plasma exchange or double-filtration plasmapheresis (PE/DFPP) significantly decreased mortality (OR = 0.236, p = 0.012). For predicting mortality after extubation, moderate-to-severe anemia before extubation (OR = 8.452, p = 0.017) and non-treated with disease-modifying therapy before MC (OR = 5.459, p = 0.031) were crucial predictive factors. CONCLUSION This study demonstrated that both old age at MC onset and moderate-to-severe anemia are important predictors of in-hospital mortality in patients with MC, and extreme leukocytosis is another crucial predictor of mortality during mechanical ventilation. The suggested mechanism is that anemia-induced hypoxia may enhance the release of proinflammatory cytokines, exacerbate systemic inflammation, and lead to multiple organ dysfunction syndrome and, finally, mortality.
Collapse
Affiliation(s)
- Che-Wei Hsu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta Pei Road, Niao Sung District, Kaohsiung, 833, Taiwan
| | - Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta Pei Road, Niao Sung District, Kaohsiung, 833, Taiwan
| | - Wei-Chin Huang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta Pei Road, Niao Sung District, Kaohsiung, 833, Taiwan
| | - Hui-Chen Lin
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta Pei Road, Niao Sung District, Kaohsiung, 833, Taiwan
| | - Wan-Chen Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta Pei Road, Niao Sung District, Kaohsiung, 833, Taiwan
| | - Chih-Cheng Huang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta Pei Road, Niao Sung District, Kaohsiung, 833, Taiwan
| | - Ben-Chung Cheng
- Department of Nephrology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Nai-Wen Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta Pei Road, Niao Sung District, Kaohsiung, 833, Taiwan.
| |
Collapse
|
15
|
Liu Q, Wang X, Wang Y, Wang C, Zhao X, Liu L, Li Z, Meng X, Guo L, Wang Y. Both Ends of Values in the Hemoglobin Spectrum Are Associated with Adverse Stroke Outcomes. Cerebrovasc Dis 2021; 51:36-44. [PMID: 34407532 DOI: 10.1159/000517868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 06/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Existing studies on the association between hemoglobin values and stroke outcomes mostly focus on the lower side and mortality, often the only and primary endpoint. The current study was conducted to assess the association between hemoglobin concentration and a variety of poor stroke outcomes in patients with acute ischemic stroke. METHODS We studied 8,321 patients enrolled in the China National Stroke Registry (CNSR) between 2007 and 2008. Patients were divided into 7 groups, and a logistic regression model was used to evaluate the association. Endpoints of interest included 1-year all-cause mortality, stroke recurrence, combined endpoint, and stroke disability. Stroke disability was defined as a modified Rankin Scale of 2-6. RESULTS Patients with low and high hemoglobin values (≤11.6 g/dL and >16.1 g/dL) had higher proportion of poststroke adverse events than those in other groups. As compared with the fourth group of hemoglobin values of 13.5-14.2 g/dL, the adjusted odds ratios (ORs) with 95% confidence interval (CI) of low hemoglobin values (≤11.6 g/dL) were 2.25 (1.72-2.93) for all-cause mortality, 1.30 (1.04-1.61) for stroke recurrence, 1.63 (1.33-2.01) for combined endpoint, and 1.37 (1.12-1.67) for stroke disability, respectively. And, the ORs of high hemoglobin values (>16.1 g/dL) for adverse stroke outcomes were 1.72 (1.25-2.37), 1.43 (1.13-1.82), 1.43 (1.13-1.81), and 1.31 (1.06-1.63), respectively. Stratified analysis showed significant interactions between sex and categories of hemoglobin values for all-cause mortality (p = 0.05), stroke recurrence (p = 0.03), and combined endpoint (p = 0.01) but not for stroke disability (p = 0.24). CONCLUSIONS Our study found both low and high hemoglobin values were associated with adverse stroke outcomes including all-cause mortality, stroke recurrence, combined endpoint, and stroke disability, which showed a U-shaped association. And, significant interactions between sex and hemoglobin concentration on all-cause mortality and stroke recurrence were also identified.
Collapse
Affiliation(s)
- Qi Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China,
| | - Xianwei 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
| | - 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
| | - Chunxue 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
| | - Xingquan Zhao
- 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
| | - Liping Liu
- 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
| | - Zixiao Li
- 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
| | - Xia Meng
- 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
| | - Li Guo
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, 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
|
16
|
Cheng X, Liu L, Li L, Zhao H, Li J, Shi J, Zhang W. Significance of CHA 2DS 2-VAS C on the severity and hemorrhagic transformation in patients with non-valvular atrial fibrillation-induced acute ischemic stroke. Intern Emerg Med 2021; 16:1155-1163. [PMID: 33386603 DOI: 10.1007/s11739-020-02558-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/30/2020] [Indexed: 12/01/2022]
Abstract
Atrial fibrillation causes a fivefold increase of stroke risk. CHA2DS2-VASC is widely used to evaluate the risk of cardiac embolism in patients with non-valvular atrial fibrillation (NVAF) and identify the patients eligible for anticoagulation therapy. This study aimed to identify the significance of CHA2DS2-VASC score on the severity and hemorrhagic transformation (HT) in patients with NVAF-induced acute ischemic stroke (NVAF-AIS). Total 113 patients diagnosed as NVAF-AIS were included in this study. Patients were categorized into severe stroke group (NIHSS > 10) and non-severe group (NIHSS ≤ 10), and the risk factors for severe stroke were investigated. Based on the results of repeated brain CT/MRI examination performed within 14 days from stroke onset or immediately in case of clinical worsening, patients were divided into HT group and non-HT group, and the predictors for HT were then analyzed. CHA2DS2-VASC score [median (interquartile range) 5 (3-5) vs. 3 (2-4); p = 0.002] in severe stroke group was significantly higher than that in non-severe group. The severe stroke group showed significantly increased prevalence of heart failure (20% vs. 48.5%, p = 0.002) and decreased hemoglobin (136.4 ± 18.0 vs.143.6 ± 15.6 g/L, p = 0.031) compared with non-severe group. Multivariate regression analysis revealed that CHA2DS2-VASc score was a powerful predictor for the severity of NVAF-AIS. Forty-seven of total recruited patients (43.2%) developed HT within 14 days after the onset of NVAF-AIS. CHA2DS2-VASc score as well as elevated glycated hemoglobin and intravenous rt-PA were the independent risk factors of HT. CHA2DS2-VASC score was closely associated with the severity of NVAF-AIS. Patients with higher CHA2DS2-VASC score were more likely to develop HT after NVAF-AIS.
Collapse
Affiliation(s)
- Xiaoling Cheng
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Liu
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lixia Li
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hui Zhao
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingjing Li
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxin Shi
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
| |
Collapse
|
17
|
Anemia Is a Risk Factor for the Development of Ischemic Stroke and Post-Stroke Mortality. J Clin Med 2021; 10:jcm10122556. [PMID: 34207841 PMCID: PMC8226740 DOI: 10.3390/jcm10122556] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/27/2021] [Accepted: 06/07/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND anemia is known to be a risk factor for developing ischemic stroke in long-term follow-up studies, and it is also known to increase the risk of death in ischemic stroke patients. We aimed to determine the association of anemia with the risk of ischemic stroke and the risk of death after ischemic stroke. METHODS The study included patients from National Health Insurance Service cohort, from January 2005 to December 2015. Anemia patients were defined as those with confirmed diagnostic codes and related medications in the sample cohort, and patients under the age of 18 were excluded. To perform a comparative analysis with the control group, twice as many patients were extracted by propensity score matching. The effects of anemia on the development of ischemic stroke were analyzed. RESULTS A total of 58,699 patients were newly diagnosed with anemia during the study period. In anemia group, the rate of ischemic stroke occurring within 1 year was 0.550%, and the rate was 0.272% in the control group. The odds ratio of anemia related to ischemic stroke was 1.602 (95% confidence intervals (CI) 1.363-1.883). During the follow-up period, 175 out of 309 (56.6%) died in anemia group, and 130 out of 314 (41.4%) died in control group. The anemia group showed a higher risk of death than the control group (Hazard ratio 1.509, 95% CI 1.197-1.902). CONCLUSION Analysis of the nationwide health insurance data revealed that anemia is one of the risk factors for the development of ischemic stroke, and also an independent prognostic factor affecting post-stroke mortality.
Collapse
|
18
|
Seystahl K, Hug A, Weber SJ, Kapitza S, Gramatzki D, Wanner M, Katan M, Luft AR, Rohrmann S, Wegener S, Weller M. Cancer is associated with inferior outcome in patients with ischemic stroke. J Neurol 2021; 268:4190-4202. [PMID: 33945004 PMCID: PMC8505392 DOI: 10.1007/s00415-021-10528-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/22/2021] [Indexed: 11/12/2022]
Abstract
Background Whether patients with stroke and cancer exhibit specific characteristics has remained controversial. Methods Medical records of patients with ischemic stroke in 2014 or 2015 registered in the Swiss Stroke Registry of Zurich were retrospectively analyzed and integrated with regional cancer registry data. Associations of clinical and outcome parameters with cancer diagnosed up to 5 years prior to stroke were tested. Results Of 753 patients with ischemic stroke, 59 patients with cancer were identified. History of venous thromboembolism (p < 0.001) was associated with cancer while age and cardiovascular risk factors were not. Higher levels of D-dimers (p = 0.001), erythrocyte sedimentation rate (p = 0.003), C-reactive protein (CRP) (p < 0.001), and lower levels of hemoglobin (p = 0.003) were associated with cancer. For platelets, pathologically low (p = 0.034) or high levels (p < 0.001) were linked to cancer. Modified Rankin scale (mRS) scores ≥ 4 on admission and at follow-up were more frequent in cancer patients (p = 0.038 and p = 0.001). Poor post-stroke survival was associated with cancer (HR 2.2, p < 0.001). Multivariable analysis identified venous thromboembolism (OR 5.1), pathologic platelet count (OR = 2.9), low hemoglobin (OR 2.5) and elevated CRP (OR 1.8) as independently associated with cancer. In multivariable Cox regression, risk for death was associated with cancer (HR 1.7), low hemoglobin (HR 2.6), mRS on admission ≥ 4 (HR 1.9), pathologic platelet count (HR 1.6), female sex (HR 1.7), and elevated CRP (HR 1.4). Conclusions Considering cancer as a cofactor for post-stroke outcome may impact clinical decision making. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10528-3.
Collapse
Affiliation(s)
- Katharina Seystahl
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland.
| | - Alessia Hug
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Sung Ju Weber
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Sandra Kapitza
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Dorothee Gramatzki
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Miriam Wanner
- Cancer Registry of the Canton of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Andreas R Luft
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland.,Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Sabine Rohrmann
- Cancer Registry of the Canton of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| |
Collapse
|
19
|
Olum S, Muyingo A, Wilson TL, Demaerschalk BM, Hoxworth JM, Zhang N, Hentz JG, Abdallah A, Kayanja A, Aguilar MI, O'Carroll CB. Stroke Mortality Outcomes in Uganda. J Stroke Cerebrovasc Dis 2021; 30:105661. [PMID: 33684710 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105661] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/15/2020] [Accepted: 02/01/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Stroke outcome data in Uganda is lacking. The objective of this study was to capture 30-day mortality outcomes in patients presenting with acute and subacute stroke to Mbarara Regional Referral Hospital (MRRH) in Uganda. METHODS A prospective study enrolling consecutive adults presenting to MRRH with abrupt onset of focal neurologic deficits suspicious for stroke, from August 2014 to March 2015. All patients had head computed tomography (CT) confirmation of ischemic or hemorrhagic stroke. Data was collected on mortality, morbidity, risk factors, and imaging characteristics. RESULTS Investigators screened 134 potential subjects and enrolled 108 patients. Sixty-two percent had ischemic and 38% hemorrhagic stroke. The mean age of all patients was 62.5 (SD 17.4), and 52% were female. More patients had hypertension in the hemorrhagic stroke group than in the ischemic stroke group (53% vs. 32%, p = 0.0376). Thirty-day mortality was 38.1% (p = 0.0472), and significant risk factors were National Institutes of Health Stroke Scale (NIHSS) score, female sex, anemia, and HIV infection. A one unit increase of the NIHSS on admission increased the risk of death at 30 days by 6%. Patients with hemorrhagic stroke had statistically higher NIHSS scores (p = 0.0408) on admission compared to patients with ischemic stroke, and also had statistically higher Modified Rankin Scale (mRS) scores at discharge (p = 0.0063), and mRS score change from baseline (p = 0.04). CONCLUSIONS Our study highlights an overall 30-day stroke mortality of 38.1% in southwestern Uganda, and identifies NIHSS at admission, female sex, anemia, and HIV infection as predictors of mortality.
Collapse
Affiliation(s)
- Sam Olum
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda; Department of Medicine, Gulu University, Lacor, Uganda.
| | - Anthony Muyingo
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Tony L Wilson
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.
| | | | | | - Nan Zhang
- Department of Biostatistics, Mayo Clinic, Phoenix, Arizona.
| | - Joseph G Hentz
- Department of Biostatistics, Mayo Clinic, Phoenix, Arizona.
| | - Amir Abdallah
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda; Department of Neurology, Mayo Clinic, Phoenix, Arizona.
| | - Adrian Kayanja
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.
| | | | | |
Collapse
|
20
|
Pienimäki JP, Protto S, Hakomäki E, Jolma P, Sillanpää N. Anemia Predicts Poor Clinical Outcome in Mechanical Thrombectomy Patients with Fair or Good Collateral Circulation. Cerebrovasc Dis Extra 2020; 10:139-147. [PMID: 33091900 PMCID: PMC7670357 DOI: 10.1159/000510228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 07/15/2020] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose Anemia predicts poor clinical outcome of ischemic stroke in the general stroke population. We studied whether this applies to those treated with mechanical thrombectomy for proximal anterior circulation occlusion in the setting of differing collateral circulation. Methods We collected the data of 347 consecutive anterior circulation stroke patients who underwent mechanical thrombectomy after multimodal CT imaging in a single tertiary stroke care center. Patients with occlusion of the internal carotid artery and/or the first segment of the middle cerebral artery were included. We recorded baseline clinical, laboratory, procedural, and imaging variables, and the technical, imaging, and clinical outcomes. Differences between anemic and nonanemic patients were studied with appropriate statistical tests and binary logistic regression analysis. Results Ninety-four out of the 285 patients eligible for analysis had anemia, and 243 had fair or good collateral circulation (collateral score, CS, >0). Fifty-four percent of the patients experienced good 3-month clinical outcome (modified Rankin Scale ≤2). In pooled analyses of the CS 1–4 and 2–4 ranges, nonanemic patients had good clinical outcome significantly more often (p < 0.001 for both). This effect was not seen in patients with poor collateral circulation (CS = 0). Nonanemic patients had significantly better odds of good clinical outcome (OR = 2.6, 95% CI 1.377–5.030, p = 0.004) in a binary regression model. A 0.1 g/dL increase in hemoglobin improved the odds of good clinical outcome by 2% (OR = 1.02, 95% CI 1.002–1.044, p = 0.03). Conclusions Low hemoglobin on admission predicts poor clinical outcome in mechanical thrombectomy patients with fair or good collateral circulation.
Collapse
Affiliation(s)
- Juha-Pekka Pienimäki
- Vascular and Interventional Radiology Center, Tampere University Hospital, Tampere, Finland
| | - Sara Protto
- Vascular and Interventional Radiology Center, Tampere University Hospital, Tampere, Finland,
| | - Eetu Hakomäki
- Vascular and Interventional Radiology Center, Tampere University Hospital, Tampere, Finland
| | - Pasi Jolma
- Department of Neurology, Tampere University Hospital, Tampere, Finland
| | - Niko Sillanpää
- Vascular and Interventional Radiology Center, Tampere University Hospital, Tampere, Finland
| |
Collapse
|
21
|
Myint PK, Macleod MJ, Clark AB, Smith TO, Bettencourt-Silva JH, Metcalf AK, Potter JF. Anaemia and incidence of post stroke dementia. Clin Neurol Neurosurg 2020; 191:105688. [DOI: 10.1016/j.clineuro.2020.105688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 11/25/2022]
|
22
|
Choi S, O'Neil SH, Joshi AA, Li J, Bush AM, Coates TD, Leahy RM, Wood JC. Anemia predicts lower white matter volume and cognitive performance in sickle and non-sickle cell anemia syndrome. Am J Hematol 2019; 94:1055-1065. [PMID: 31259431 DOI: 10.1002/ajh.25570] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/25/2019] [Accepted: 06/26/2019] [Indexed: 12/13/2022]
Abstract
Severe chronic anemia is an independent predictor of overt stroke, white matter damage, and cognitive dysfunction in the elderly. Severe anemia also predisposes to white matter strokes in young children, independent of the anemia subtype. We previously demonstrated symmetrically decreased white matter (WM) volumes in patients with sickle cell disease (SCD). In the current study, we investigated whether patients with non-sickle anemia also have lower WM volumes and cognitive dysfunction. Magnetic Resonance Imaging was performed on 52 clinically asymptomatic SCD patients (age = 21.4 ± 7.7; F = 27, M = 25; hemoglobin = 9.6 ± 1.6 g/dL), 26 non-sickle anemic patients (age = 23.9 ± 7.9; F = 14, M = 12; hemoglobin = 10.8 ± 2.5 g/dL) and 40 control subjects (age = 27.7 ± 11.3; F = 28, M = 12; hemoglobin = 13.4 ± 1.3 g/dL). Voxel-wise changes in WM brain volumes were compared to hemoglobin levels to identify brain regions that are vulnerable to anemia. White matter volume was diffusely lower in deep, watershed areas proportionally to anemia severity. After controlling for age, sex, and hemoglobin level, brain volumes were independent of disease. WM volume loss was associated with lower Full Scale Intelligence Quotient (FSIQ; P = .0048; r2 = .18) and an abnormal burden of silent cerebral infarctions (P = .029) in males, but not in females. Hemoglobin count and cognitive measures were similar between subjects with and without white-matter hyperintensities. The spatial distribution of volume loss suggests chronic hypoxic cerebrovascular injury, despite compensatory hyperemia. Neurocognitive consequences of WM volume changes and silent cerebral infarction were strongly sexually dimorphic. Understanding the possible neurological consequences of chronic anemia may help inform our current clinical practices.
Collapse
Affiliation(s)
- Soyoung Choi
- Neuroscience Graduate ProgramUniversity of Southern California Los Angeles California
- Signal and Image Processing InstituteUniversity of Southern California Los Angeles California
- Division of Hematology, Oncology and Blood and Marrow TransplantationChildren's Hospital Los Angeles Los Angeles California
| | - Sharon H. O'Neil
- The Saban Research Institute, Children's Hospital Los Angeles Los Angeles California
- Division of NeurologyChildren's Hospital Los Angeles Los Angeles California
- Department of Pediatrics, Keck School of MedicineUniversity of Southern California Los Angeles California
| | - Anand A. Joshi
- Signal and Image Processing InstituteUniversity of Southern California Los Angeles California
| | - Jian Li
- Signal and Image Processing InstituteUniversity of Southern California Los Angeles California
| | - Adam M. Bush
- Division of Hematology, Oncology and Blood and Marrow TransplantationChildren's Hospital Los Angeles Los Angeles California
- Biomedical EngineeringUniversity of Southern California Los Angeles California
- Radiology DepartmentStanford University Stanford California
| | - Thomas D. Coates
- Division of Hematology, Oncology and Blood and Marrow TransplantationChildren's Hospital Los Angeles Los Angeles California
- Department of Pediatrics, Keck School of MedicineUniversity of Southern California Los Angeles California
| | - Richard M. Leahy
- Neuroscience Graduate ProgramUniversity of Southern California Los Angeles California
- Signal and Image Processing InstituteUniversity of Southern California Los Angeles California
| | - John C. Wood
- Division of Hematology, Oncology and Blood and Marrow TransplantationChildren's Hospital Los Angeles Los Angeles California
- Department of Pediatrics, Keck School of MedicineUniversity of Southern California Los Angeles California
| |
Collapse
|
23
|
Is hemoglobin good for cerebral oxygenation and clinical outcome in acute brain injury? Curr Opin Crit Care 2019; 24:91-96. [PMID: 29401175 DOI: 10.1097/mcc.0000000000000485] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the role of hemoglobin in cerebral physiology and pathophysiology. We review the existing as well as recent evidence detailing the effects of red blood cell transfusion on cerebral oxygenation and clinical outcome. RECENT FINDINGS Hemoglobin is a key component in oxygen delivery, and thus cerebral oxygenation. Higher hemoglobin levels and red blood cell transfusion are associated with higher cerebral oxygen delivery and decreased cerebral ischemic burden. Recent studies suggest that this may be associated with improved clinical outcomes. However, these results are limited to only a few, small studies and the results have not been consistent. Further studies are required. SUMMARY Hemoglobin is important for cerebral oxygenation and strategies to minimize anemia should be undertaken. Although higher hemoglobin levels are associated with less cerebral ischemia and better clinical outcome, whether this remains true whenever red blood cell transfusion is used to achieve this result remains unclear.
Collapse
|
24
|
Gürdoğan M, Kehaya S, Korkmaz S, Altay S, Özkan U, Kaya Ç. The Relationship between Diffusion-Weighted Magnetic Resonance Imaging Lesions and 24-Hour Rhythm Holter Findings in Patients with Cryptogenic Stroke. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E38. [PMID: 30720741 PMCID: PMC6409892 DOI: 10.3390/medicina55020038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 01/23/2019] [Accepted: 01/31/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Cranial magnetic resonance imaging findings of patients considered to be cryptogenic stroke may be useful in determining the clinical and prognostic significance of arrhythmias, such as atrial premature beats and atrial run attacks, that are frequently encountered in rhythm Holter analysis. This study was conducted to investigate the relationship between short atrial runs and frequent premature atrial contractions detected in Holter monitors and infarct distributions in cranial magnetic resonance imaging of patients diagnosed with cryptogenic stroke. MATERIALS AND METHODS We enrolled the patients with acute ischemic stroke whose etiology were undetermined. We divided the patients in two groups according to diffusion-weighted magnetic resonance imaging as single or multiple vascular territory acute infarcts. The demographic, clinical, laboratory, echocardiographic, and rhythm Holter analyses were compared. RESULTS The study investigated 106 patients diagnosed with cryptogenic stroke. Acute cerebral infarctions were detected in 31% of the investigated patients in multiple territories and in 69% in a single territory. In multivariate logistic regression analysis, the total premature atrial contraction count (OR = 1.002, 95% CI: 1.001⁻1.004, p = 0.001) and short atrial run count (OR = 1.086, 95% CI: 1.021⁻1.155, p = 0.008) were found as independent variables that could distinguish between infarctions in a single or in multiple vascular territories. CONCLUSIONS Rhythm Holter monitoring of patients with infarcts detected in multiple vascular territories showed significantly higher premature atrial contractions and short atrial run attacks. More effort should be devoted to the identification of cardioembolic etiology in cryptogenic stroke patients with concurrent acute infarcts in the multiple vascular territories of the brain.
Collapse
Affiliation(s)
- Muhammet Gürdoğan
- Department of Cardiology, School of Medicine, Trakya University, 22030 Edirne, Turkey.
| | - Sezgin Kehaya
- Department of Neurology, School of Medicine, Trakya University, 22030 Edirne, Turkey.
| | - Selçuk Korkmaz
- Department of Biostatistics and Medical Informatics, School of Medicine, Trakya University, 22030 Edirne, Turkey.
| | - Servet Altay
- Department of Cardiology, School of Medicine, Trakya University, 22030 Edirne, Turkey.
| | - Uğur Özkan
- Department of Cardiology, School of Medicine, Trakya University, 22030 Edirne, Turkey.
| | - Çağlar Kaya
- Department of Cardiology, School of Medicine, Trakya University, 22030 Edirne, Turkey.
| |
Collapse
|
25
|
Liu K, Song B, Gao Y, Zhao L, Fang H, Wang Y, Pei L, Han K, Li S, Li Y, Xu Y. Long-Term Outcomes in Patients with Anemia And Cerebral Venous Thrombosis. Neurocrit Care 2018; 29:463-468. [PMID: 29987689 DOI: 10.1007/s12028-018-0544-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anemia is associated with unfavorable functional outcome in ischemic and hemorrhagic stroke. However, the relationship between anemia and prognosis in patients with cerebral venous thrombosis (CVT) has not been studied. METHODS Consecutive CVT patients were retrospectively identified from November 2011, through January 2017. Anemia was defined according to the World Health Organization criteria (non-pregnant female hemoglobin level < 120 g/L, pregnant female < 110 g/L and male < 130 g/L), which was further classified as mild, moderate, and severe anemia according to hemoglobin concentration, and as microcytic, normocytic, and macrocytic anemia according to mean corpuscular volume. Unfavorable outcome was defined as modified Rankin Scale (mRS) of 3-6. Factors such as age, sex, coma, malignancy, intracerebral hemorrhage, and straight sinus and/or deep CVT involved, premorbid mRS were adjusted to evaluate the relationship between anemia and prognosis in CVT patients. RESULTS A total of 238 CVT patients were included, among whom 73 patients (30.67%) were diagnosed with anemia. Multivariate logistic regression analysis showed that patients with anemia had a higher risk of mRS of 3-6 (OR = 3.62; 95% CI, 1.45-9.01; P = 0.006) and mortality (OR = 5.46; 95% CI, 1.90-15.70; P = 0.002). Subgroup analysis showed that severe anemia was independently associated with mRS of 3-6 (OR = 8.80; 95% CI, 1.90-40.81; P = 0.005) and mortality (OR = 9.82; 95% CI, 1.81-53.25; P = 0.010). Similarly, microcytic anemia increased the risk of mRS of 3-6 (OR = 4.64; 95% CI, 1.48-14.52; P = 0.008) and mortality (OR = 9.68; 95% CI, 2.61-35.91; P = 0.001). In addition, our study also revealed that lower hemoglobin level, evaluated as a continuous variable, was inversely associated with mRS of 3-6 (OR = 0.98; 95% CI, 0.96-0.99; P = 0.007) and mortality (OR = 0.97; 95% CI, 0.95-0.99; P = 0.005). CONCLUSIONS Anemia was a significant and independent predictor of unfavorable functional outcome in patients with CVT.
Collapse
Affiliation(s)
- Kai Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Bo Song
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Yuan Gao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Lu Zhao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Hui Fang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Yunchao Wang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Lulu Pei
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Kaihao Han
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Shen Li
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Yusheng Li
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China
| | - Yuming Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan Province, China.
| |
Collapse
|
26
|
Khan MF, Shamael I, Zaman Q, Mahmood A, Siddiqui M. Association of Anemia with Stroke Severity in Acute Ischemic Stroke Patients. Cureus 2018; 10:e2870. [PMID: 30148022 PMCID: PMC6107329 DOI: 10.7759/cureus.2870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective: To investigate the association of anemia with stroke severity in acute ischemic stroke patients. Material & methods: We enrolled 96 patients (mean age: 60.25 ± 11.92 years old) who were admitted to the stroke unit of Shifa International Hospital between 1st March 2015 and 31st August 2015. Each patient presented within 72 hours of onset of symptoms, underwent computed tomography (CT) of the head and blood tests, including hemoglobin concentration, on the first day of hospitalization. Stroke severity was assessed on admission using the National Institute of Health Stroke Scale. Anemia was evaluated according to the World Health Organization (WHO) criteria (men, <13 g/dL; women, <12 g/dL). We examined the frequency of anemia in patients with different severities of acute ischemic stroke. Results: World Health Organization defined anemia was positive in 38 (39.6%) and negative in 58 (60.4%) patients. Among the patients who were positive for anemia, seven (18.4%) had a minor stroke, 10 (26.3%) had a moderately severe stroke, and 21 (55.3%) had a severe stroke. There was a significant association between anemia and stroke severity (P-value 0.000). Conclusion: Our data indicated that anemia was a frequent finding in acute ischemic stroke patients, with increasing frequency corresponding to stroke severity.
Collapse
Affiliation(s)
| | | | - Qamar Zaman
- Neurology, Shifa International Hospital, Islamabad, PAK
| | - Asad Mahmood
- Medicine, Queens Medical Center, Nottingham, GBR
| | | |
Collapse
|
27
|
Sharma K, Johnson DJ, Johnson B, Frank SM, Stevens RD. Hemoglobin concentration does not impact 3-month outcome following acute ischemic stroke. BMC Neurol 2018; 18:78. [PMID: 29859542 PMCID: PMC5985053 DOI: 10.1186/s12883-018-1082-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is uncertainty regarding the effect of anemia and red blood cell transfusion on functional outcome following acute ischemic stroke. We studied the relationship of hemoglobin parameters and red cell transfusion with post stroke functional outcome after adjustment for neurological severity and medical comorbidities. METHODS Retrospective cohort study of 536 patients discharged with a diagnosis of ischemic stroke from a tertiary care hospital between January 2012 and April 2015. Hemoglobin level at hospital admission, lowest recorded value during hospitalization (nadir), delta hemoglobin (admission minus nadir), red cell transfusion during hospitalization were noted. Charlson Comorbidity Index (CCI) was computed as a summary measure of medical comorbidities. A multivariable logistic regression model was used to determine risk-adjusted odds of unfavorable outcome, defined as a modified Rankin Score of > 2. RESULTS Anemia was present on hospital admission in 31% of patients. Forty five percent of patients had unfavorable outcome. In the univariable analysis increasing age, admission National Institutes of Health Stroke Scale (NIHSS), CCI, nadir hemoglobin, delta hemoglobin and blood transfusion were associated with unfavorable outcome. In the multivariable model, only increasing age, CCI and NIHSS remained associated with unfavorable outcome. No quadratic association was found on repeating the model to identify a possible U-shaped relationship of hemoglobin with outcome. CONCLUSIONS Our findings contradict prior observational studies and highlight an area of clinical equipoise regarding the optimal management of anemia in patients hospitalized for ischemic stroke. This uncertainty could be addressed with appropriately designed clinical trials.
Collapse
Affiliation(s)
- Kartavya Sharma
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA. .,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA. .,Department of Neurology, University of Kansas Medical Center, Mailstop 2012, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA.
| | - Daniel J Johnson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Brenda Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
| |
Collapse
|
28
|
Wei CC, Zhang ST, Tan G, Zhang SH, Liu M. Impact of anemia on in-hospital complications after ischemic stroke. Eur J Neurol 2018; 25:768-774. [PMID: 29431886 DOI: 10.1111/ene.13595] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/06/2018] [Indexed: 02/05/2023]
Affiliation(s)
- C.-C. Wei
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - S.-T. Zhang
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - G. Tan
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - S.-H. Zhang
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - M. Liu
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| |
Collapse
|
29
|
Abe A, Sakamoto Y, Nishiyama Y, Suda S, Suzuki K, Aoki J, Kimura K. Decline in Hemoglobin during Hospitalization May Be Associated with Poor Outcome in Acute Stroke Patients. J Stroke Cerebrovasc Dis 2018; 27:1646-1652. [PMID: 29478940 DOI: 10.1016/j.jstrokecerebrovasdis.2018.01.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/07/2018] [Accepted: 01/23/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND AND PURPOSE Anemia upon hospital admission is a known predictor of poor functional outcomes in patients with acute cerebral infarction. However, it remains unclear whether reductions in hemoglobin levels during hospitalization influence stroke outcomes. We investigated the association between in-hospital decline in hemoglobin and poor outcomes. MATERIALS AND METHODS We retrospectively analyzed data from 480 consecutive patients who had experienced acute cerebral infarction and presented without anemia between January 2012 and March 2015. Decline in hemoglobin was taken as the difference between hemoglobin levels upon admission and nadir hemoglobin. Poor outcome was defined as a modified Rankin Scale score 3-6. A multivariate analysis of the relationship between decline in hemoglobin and poor outcome at discharge was conducted for various patient characteristics. RESULTS The mean hemoglobin level at admission was 14.3 ± 1.3 g/dL, whereas the mean nadir hemoglobin value was 13.1 ± 1.9 g/dL, with a mean decline in hemoglobin of 1.3 ± 1.5 g/dL. In patients with poor outcomes, mean decline in hemoglobin was significantly reduced to 3.1 g/dL (P < .001). The optimal cutoff decline in hemoglobin required to distinguish a poor outcome was 1.5 g/dL whereas the sensitivity and specificity were 62% and 82.3%, respectively, with an area under the curve of .77 (P < .0001). A decline in hemoglobin below 1.5 g/dL was found to be an independent predictor of poor outcome (odds ratio: 2.10; confidence interval: 1.10-3.99; P = .023). CONCLUSION Decline in hemoglobin in patients hospitalized with acute stroke may be associated with poor outcome.
Collapse
Affiliation(s)
- Arata Abe
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
| | - Yuki Sakamoto
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yasuhiro Nishiyama
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Satoshi Suda
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kentaro Suzuki
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Junya Aoki
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
30
|
Akpinar CK, Gurkas E, Aytac E. Moderate to Severe Anemia Is Associated with Poor Functional Outcome in Acute Stroke Patients Treated with Mechanical Thrombectomy. INTERVENTIONAL NEUROLOGY 2017; 7:12-18. [PMID: 29628940 DOI: 10.1159/000480642] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Anemia will negatively affect cerebral collaterals and penumbra. Eventually, it may cause worse clinical outcomes and even increase mortality rates in stroke patients. Anemia has recently been suggested to be an independent risk factor for ischemic stroke. Therefore, we aimed to investigate the effects of the presence of anemia on clinical outcomes in ischemic stroke patients undergoing mechanical thrombectomy. Methods This was a retrospective study involving the prospectively and consecutively collected data of 90 adult patients between January 2015 and August 2016. Hemoglobin (Hb) cutoff levels were accepted as 12 g/dL for women and 13 g/dL for men. Patients having anemia were further divided into three subgroups as severe anemia (Hb <8 g/dL for both genders), moderate anemia (Hb <10 g/dL for both genders), and mild anemia (Hb <13 g/dL for men and Hb <12 g/dL for women). Results Forty of the subjects (44.4%) had anemia. Moderate anemia was detected in 14 out of 90 patients (15.5%) and severe anemia was found in only four of them (4.4%). Poor functional outcome (mRS 3-6) was similar in both anemic and non-anemic patients (37.5% vs. 38%, respectively, p = 0.08), but poor functional outcome was found to be statistically significant with severe anemic group (Hb <8 mg/dL) (p = 0.003). In multiple logistic regression analysis, moderate and severe anemia has been found to increase the mortality (p = 0.032). Conclusions Our study demonstrated a poor functional outcome only in moderate to severe anemic patients. Clinicians should keep in mind the negative effect of moderate to severe anemia in the clinical course of acute stroke patients treated with mechanical thrombectomy.
Collapse
Affiliation(s)
| | - Erdem Gurkas
- Neurology Clinic, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Emrah Aytac
- Neurology, Medical Faculty, Firat University, Elazig, Turkey
| |
Collapse
|
31
|
Barlas RS, McCall SJ, Bettencourt-Silva JH, Clark AB, Bowles KM, Metcalf AK, Mamas MA, Potter JF, Myint PK. Impact of anaemia on acute stroke outcomes depends on the type of anaemia: Evidence from a UK stroke register. J Neurol Sci 2017; 383:26-30. [PMID: 29246615 DOI: 10.1016/j.jns.2017.09.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/13/2017] [Accepted: 09/29/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Previous research has demonstrated an association between anaemia and poor outcomes in acute stroke. This study aimed to assess the impact of anaemia on stroke by anaemia subtype. METHODS Data from a prospective UK Regional Stroke Register were used to assess the association between hypochromic microcytic and normochromic normocytic anaemia on inpatient-mortality, length of stay (LOS) and discharge modified Rankin scale (mRS). Analysis was stratified by stroke subtypes and multivariable logistic regression, adjusting for potential confounders, was used to quantify this association. Patients who were not anaemic were the reference category. RESULTS A total of 8167 stroke patients (admitted between 2003 and 2015) were included, mean age (SD) 77.39±11.90years. Of these, 3.4% (n=281) had hypochromic microcytic anaemia and 15.5% (n=1262) had normochromic normocytic anaemia on admission. Normochromic normocytic anaemia was associated with increased odds of in-patient mortality OR 1.48 (1.24-1.77), 90-day mortality OR 1.63 (1.38-1.92), longer LOS OR 1.21 (1.06-1.40), defined as >7days, and severe disability defined as discharge mRS≥3 OR 1.31 (1.06-1.63), in patients with ischaemic stroke. Hypochromic microcytic anaemia was associated with 90-day mortality OR 1.90 (1.40-2.58) and a longer LOS OR 1.57 (1.20-2.05) in patients with ischaemic stroke. CONCLUSIONS Hypochromic microcytic and normochromic normocytic anaemia are associated with differing outcomes in terms of inpatient mortality and post stroke disability. While it is unclear if anaemia per se or another underlying cause is responsible for adverse outcomes, subtype of anaemia appears to be relevant in stroke prognosis.
Collapse
Affiliation(s)
- Raphae S Barlas
- Ageing Clinical and Experimental Research (ACER), Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
| | - Stephen J McCall
- Ageing Clinical and Experimental Research (ACER), Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK; National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Allan B Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Anthony K Metcalf
- Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine, Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - John F Potter
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Phyo K Myint
- Ageing Clinical and Experimental Research (ACER), Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK; Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, UK; Norwich Medical School, University of East Anglia, Norwich, UK.
| |
Collapse
|
32
|
Kaiafa G, Savopoulos C, Kanellos I, Mylonas KS, Tsikalakis G, Tegos T, Kakaletsis N, Hatzitolios AI. Anemia and stroke: Where do we stand? Acta Neurol Scand 2017; 135:596-602. [PMID: 27480069 DOI: 10.1111/ane.12657] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2016] [Indexed: 02/03/2023]
Abstract
Anemia seems to have a clear relationship with cerebrovascular events (CVEs), as there is a direct connection between central nervous system, blood supply, and tissue oxygen delivery. Anemia is considered a hyperkinetic state which disturbs endothelial adhesion molecule genes that may lead to thrombus formation. Furthermore, blood flow augmentation and turbulence may result in the migration of this thrombus, thus producing artery-to-artery embolism. It is for this reason that anemia is characterized as "the fifth cardiovascular risk factor." Anemia is consistently present in patients with acute stroke, ranging from 15% to 29%, while the mortality rate was significantly higher in patients suffering from anemia at the time of admission. Different types of anemia (sickle cell disease, beta thalassemia, iron deficiency anemia [IDA]) have been associated with increased cardiovascular and CVE risk. The relation between hemoglobin level and stroke would require further investigation. Unfortunately, treatment of anemia in cardiovascular and cerebrovascular disease still lacks clear targets and specific therapy has not developed. However, packed red blood cell transfusion is generally reserved for therapy in patients with CVEs. What is more, treatment of IDA prevents thrombosis and the occurrence of stroke; although iron levels should be checked, chronic administration favors thrombosis. Regarding erythropoietin (EPO), as there is lack of studies in anemic stroke patients, it would be desirable to utilize both neuroprotective and hematopoietic properties of EPO in anemic stroke patients. This review aims to clarify the poorly investigated and defined issues concerning the relation of anemia and CVEs.
Collapse
Affiliation(s)
- G. Kaiafa
- First Propaedeutic Department of Internal Medicine; AHEPA University Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - C. Savopoulos
- First Propaedeutic Department of Internal Medicine; AHEPA University Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - I. Kanellos
- First Propaedeutic Department of Internal Medicine; AHEPA University Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - K. S. Mylonas
- First Propaedeutic Department of Internal Medicine; AHEPA University Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - G. Tsikalakis
- First Propaedeutic Department of Internal Medicine; AHEPA University Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - T. Tegos
- First Department of Neurology; AHEPA University Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - N. Kakaletsis
- First Propaedeutic Department of Internal Medicine; AHEPA University Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
- First Department of Neurology; AHEPA University Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - A. I. Hatzitolios
- First Propaedeutic Department of Internal Medicine; AHEPA University Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| |
Collapse
|
33
|
Skalny AV, Klimenko LL, Turna AA, Budanova MN, Baskakov IS, Savostina MS, Mazilina AN, Deyev AI, Skalnaya MG, Tinkov AA. Serum trace elements are associated with hemostasis, lipid spectrum and inflammatory markers in men suffering from acute ischemic stroke. Metab Brain Dis 2017; 32:779-788. [PMID: 28220282 DOI: 10.1007/s11011-017-9967-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 02/07/2017] [Indexed: 12/16/2022]
Abstract
The primary objective of the study is investigation of the association between trace elements status and hemostasis, lipid spectrum and inflammatory markers in acute ischemic stroke (AIS). A total of 30 men suffering from AIS and 30 healthy controls were involved in the current survey. Blood count, serum lipid spectrum, complement components C4 and C3a, vascular endothelial growth factor (VEGF), S100B protein, NR2 antibodies (NR2Ab), and total antioxidant status (TAS), as well as plasma fibrinogen, and D-dimer levels and activated partial thromboplastin time (APTT) were assessed. Serum trace elements were analyzed using inductively coupled plasma mass spectrometry. AIS patients were characterized by significantly increased fibrinogen, D-dimer, TG, C3a, C4, NR2Ab, and VEGF levels. The leukocyte count, erythrocyte sedimentation rate and serum atherogenic index were also increased in stroke patients. Oppositely, TAS and APTT values, bleeding and blood coagulation time were decreased. AIS patients were characterized by significantly decreased serum Fe and Co concentrations, whereas the level of Cu, I, Li, Mn, Se, Zn, As, Pb, Ni, and especially V and B in serum was significantly increased. Serum V and B tightly correlated with the procoagulant state and inflammatory markers. Multiple regression analysis revealed a significant inverse association between serum Se levels and stroke markers after adjustment for covariates. Therefore, it is hypothesized that elements like vanadium and boron may be closely involved in stroke pathogenesis by modulation of hemostasis and inflammation, whereas the observed increase in Se levels may be considered as a compensatory reaction.
Collapse
Affiliation(s)
- Anatoly V Skalny
- All-Russian Research Institute of Medicinal and Aromatic Plants (VILAR), Moscow, 117216, Russia
- Yaroslavl State University, Yaroslavl, 150000, Russia
- Orenburg State University, Orenburg, 460018, Russia
- RUDN University, Moscow, 117198, Russia
| | - Lydmila L Klimenko
- Institute of Chemical Physics of N. N. Semenov of the Russian Academy of Sciences, Moscow, 117977, Russia
| | - Aliya A Turna
- Institute of Professional Development of Federal Medical-Biological Agency of Russia, 125371, Moscow, Russia
| | - Maria N Budanova
- Institute of Chemical Physics of N. N. Semenov of the Russian Academy of Sciences, Moscow, 117977, Russia
| | - Ivan S Baskakov
- Institute of Chemical Physics of N. N. Semenov of the Russian Academy of Sciences, Moscow, 117977, Russia
| | - Marina S Savostina
- Federal Scientific Clinical Centre for Physico-Chemical Medicine of Federal Medical-Biological Agency of Russia, 143000, Odintsovo, Moscow Region, Russia
| | - Aksana N Mazilina
- Federal Scientific Clinical Centre for Physico-Chemical Medicine of Federal Medical-Biological Agency of Russia, 143000, Odintsovo, Moscow Region, Russia
| | - Anatoly I Deyev
- Institute of Chemical Physics of N. N. Semenov of the Russian Academy of Sciences, Moscow, 117977, Russia
- N. I. Pirogov Russian National Research Medical University, 117997, Moscow, Russia
| | | | - Alexey A Tinkov
- Yaroslavl State University, Yaroslavl, 150000, Russia.
- Orenburg State University, Orenburg, 460018, Russia.
- RUDN University, Moscow, 117198, Russia.
- Orenburg State Medical University, Orenburg, 460000, Russia.
| |
Collapse
|
34
|
Ischemic Stroke Mortality Is More Strongly Associated with Anemia on Admission Than with Underweight Status. J Stroke Cerebrovasc Dis 2017; 26:1369-1374. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 01/04/2023] Open
|
35
|
Kataoka H, Tsuchiya K, Naganuma T, Okazaki M, Komatsu M, Kimura T, Shiohira S, Kawaguchi H, Nitta K. Relationship between anaemia management at haemodialysis initiation and patient prognosis. Nephrology (Carlton) 2016; 20 Suppl 4:14-21. [PMID: 26456159 DOI: 10.1111/nep.12639] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM It has been suggested that anaemia management during a transition period to haemodialysis could influence prognosis. In this paper, we have conducted a retrospective investigation on how Hb levels at haemodialysis initiation in patients with chronic kidney disease (CKD) influence the risk of cerebral infarction and cardiovascular events. METHODS Seventy-two patients who underwent initial haemodialysis between May 2012 and April 2014 were designated as subjects of the study and the patients were divided into a cohort with Hb levels ≥8 g/dL and a cohort with <8 g/dL at haemodialysis initiation. The occurrence of cardiovascular events was analyzed using the Kaplan-Meier method and Cox proportional hazards model. RESULTS The cohort with <8 g/dL Hb levels at haemodialysis initiation demonstrated a tendency toward low dosage of ESA or iron preparation in the pre-haemodialysis (maintenance) phase. Significant incidence of cardiovascular (log rank, P = 0.002) and cerebrovascular (log rank, P = 0.02) events was observed. The results of multivariate analysis of the Cox proportional hazards model indicated that anaemia with <8 g/dL Hb levels at haemodialysis initiation was a significant risk factor for coronary artery (hazard ratio = 12.85, P = 0.003) and cerebrovascular (hazard ratio = 5.11, P = 0.04) diseases post-haemodialysis. CONCLUSION The results of this investigation indicate the possible involvement of low Hb levels at haemodialysis initiation as a factor in cardio- and cerebrovascular events. There, our results suggested that the administration of adequate dosage of iron preparations and ESA in the pre-haemodialysis period could help prevent cardio- and cerebrovascular events.
Collapse
Affiliation(s)
- Hiroshi Kataoka
- Department of Medicine IV, Tokyo Women's Medical University, Tokyo, Japan
| | - Ken Tsuchiya
- Department of Medicine IV, Tokyo Women's Medical University, Tokyo, Japan
| | | | | | - Mizuki Komatsu
- Department of Nephrology, Jyoban Hospital, Fukushima, Japan
| | | | - Shunji Shiohira
- Department of Medicine IV, Tokyo Women's Medical University, Tokyo, Japan.,Department of Nephrology, Jyoban Hospital, Fukushima, Japan
| | | | - Kosaku Nitta
- Department of Medicine IV, Tokyo Women's Medical University, Tokyo, Japan
| |
Collapse
|
36
|
Barlas RS, Honney K, Loke YK, McCall SJ, Bettencourt-Silva JH, Clark AB, Bowles KM, Metcalf AK, Mamas MA, Potter JF, Myint PK. Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke: Analysis of UK Regional Registry Data, Systematic Review, and Meta-Analysis. J Am Heart Assoc 2016; 5:JAHA.115.003019. [PMID: 27534421 PMCID: PMC5015269 DOI: 10.1161/jaha.115.003019] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The impact of hemoglobin levels and anemia on stroke mortality remains controversial. We aimed to systematically assess this association and quantify the evidence. METHODS AND RESULTS We analyzed data from a cohort of 8013 stroke patients (mean±SD, 77.81±11.83 years) consecutively admitted over 11 years (January 2003 to May 2015) using a UK Regional Stroke Register. The impact of hemoglobin levels and anemia on mortality was assessed by sex-specific values at different time points (7 and 14 days; 1, 3, and 6 months; 1 year) using multiple regression models controlling for confounders. Anemia was present in 24.5% of the cohort on admission and was associated with increased odds of mortality at most of the time points examined up to 1 year following stroke. The association was less consistent for men with hemorrhagic stroke. Elevated hemoglobin was also associated with increased mortality, mainly within the first month. We then conducted a systematic review using the Embase and Medline databases. Twenty studies met the inclusion criteria. When combined with the cohort from the current study, the pooled population had 29 943 patients with stroke. The evidence base was quantified in a meta-analysis. Anemia on admission was found to be associated with an increased risk of mortality in both ischemic stroke (8 studies; odds ratio 1.97 [95% CI 1.57-2.47]) and hemorrhagic stroke (4 studies; odds ratio 1.46 [95% CI 1.23-1.74]). CONCLUSIONS Strong evidence suggests that patients with anemia have increased mortality with stroke. Targeted interventions in this patient population may improve outcomes and require further evaluation.
Collapse
Affiliation(s)
- Raphae S Barlas
- Epidemiology Group, Institute of Applied Health Sciences, Aberdeen, UK
| | - Katie Honney
- Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Stephen J McCall
- Epidemiology Group, Institute of Applied Health Sciences, Aberdeen, UK Nuffield Department of Population Health, University of Oxford, UK
| | | | - Allan B Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Anthony K Metcalf
- Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - John F Potter
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Phyo K Myint
- Epidemiology Group, Institute of Applied Health Sciences, Aberdeen, UK Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, UK Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
37
|
Wang CH, Huang CH, Chang WT, Tsai MS, Yu PH, Wang AY, Chen NC, Chen WJ. Association between hemoglobin levels and clinical outcomes in adult patients after in-hospital cardiac arrest: a retrospective cohort study. Intern Emerg Med 2016; 11:727-36. [PMID: 26758060 DOI: 10.1007/s11739-015-1386-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 12/24/2015] [Indexed: 01/06/2023]
Abstract
In addition to cardiac output, oxygen delivery is determined by the amount of oxygen carried by hemoglobin, which is estimated by the product of hemoglobin level and peripheral hemoglobin oxygen saturation (SpO2). Optimal hemoglobin concentration for post-cardiac arrest syndrome (PCAS) has not yet been investigated thoroughly. We conducted a retrospective observational study in a single medical center. We included adult patients between 2006 and 2012 who experienced in-hospital cardiac arrest, and achieved sustained return of spontaneous circulation (ROSC). We used multivariable logistic regression analysis to identify factors associated with favorable neurological status at hospital discharge, defined as a score of 1 or 2 on the Cerebral Performance Category scale. Minimum hemoglobin concentration and SpO2 during the initial 24 h after ROSC were used for analysis. Anemia was defined by the World Health Organization criteria as a hemoglobin concentration <12 g/dL in women and <13 g/dL in men. Of the 426 patients included in our analysis, 387 patients (90.8 %) met the criteria for anemia. The mean minimum hemoglobin concentration among all the patients was 9.2 g/dL. The product of hemoglobin × SpO2 was correlated with a favorable neurological outcome (odds ratio 1.003, 95 % confidence interval 1.002-1.004). According to recommended SpO2 by resuscitation guidelines (94-98 %), we calculated the corresponding range of minimum required hemoglobin concentration to be 8.6-9.0 g/dL for a favorable neurological outcome. Anemia common among PCAS patients. Neurological outcome in PCAS might be correlated with hemoglobin concentration following resuscitation.
Collapse
Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, No. 579, Sec. 2, Yunlin Rd., Douliu City, 640, Yunlin County, Taiwan, ROC
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Ping-Hsun Yu
- Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, No. 127, Siyuan Rd., Xinzhuang Dist., New Taipei City, 242, Taiwan, ROC
| | - An-Yi Wang
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC
| | - Nai-Chuan Chen
- Department of Emergency Medicine, Tao Yuan General Hospital, Ministry of Health and Welfare, No. 1492, Zhongshan Rd., Taoyuan Dist., Taoyuan City, 330, Taiwan, ROC
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan, ROC.
- Department of Emergency Medicine, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan, ROC.
| |
Collapse
|
38
|
Lelubre C, Bouzat P, Crippa IA, Taccone FS. Anemia management after acute brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:152. [PMID: 27311626 PMCID: PMC4911680 DOI: 10.1186/s13054-016-1321-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Anemia is frequent among brain-injured patients, where it has been associated with an increased risk of poor outcome. The pathophysiology of anemia in this patient population remains multifactorial; moreover, whether anemia merely reflects a higher severity of the underlying disease or is a significant determinant of the neurological recovery of such patients remains unclear. Interestingly, the effects of red blood cell transfusions (RBCT) in moderately anemic patients remain controversial; although hemoglobin levels are increased, different studies observed only a modest and inconsistent improvement in cerebral oxygenation after RBCT and raised serious concerns about the risk of increased complications. Thus, considering this "blood transfusion anemia paradox", the optimal hemoglobin level to trigger RBCT in brain-injured patients has not been defined yet; also, there is insufficient evidence to provide strong recommendations regarding which hemoglobin level to target and which associated transfusion strategy (restrictive versus liberal) to select in this patient population. We summarize in this review article the more relevant studies evaluating the effects of anemia and RBCT in patients with an acute neurological condition; also, we propose some potential strategies to optimize transfusion management in such patients.
Collapse
Affiliation(s)
- Christophe Lelubre
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium.,Laboratoire de Médecine Expérimentale, Université Libre de Bruxelles (ULB) - Unité 222, CHU Charleroi (Hôpital André Vésale), Rue de Gozée 706, Montigny-Le-Tilleul, Belgium
| | - Pierre Bouzat
- Department of Anaesthesiology and Critical Care, Grenoble University Hospital, Hôpital Albert Michallon, Avenue Maquis du Grésivaudan, Grenoble, F-38043, France.,Grenoble Neurosciences Institute, Grenoble Alpes University, Grenoble, F-38043, France
| | - Ilaria Alice Crippa
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium.
| |
Collapse
|
39
|
Anemia increases the mortality risk in patients with stroke: A meta-analysis of cohort studies. Sci Rep 2016; 6:26636. [PMID: 27211606 PMCID: PMC4876389 DOI: 10.1038/srep26636] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 05/06/2016] [Indexed: 01/08/2023] Open
Abstract
The impact of anemia on the outcome of patients with stroke remains inconsistent. We performed a meta-analysis of cohort studies to assess the mortality risk in stroke patients with and without anemia. Systematic searches were conducted in the PubMed, China National Knowledge Infrastructure, Web of Science and Wanfang databases to identify relevant studies from inception to November 2015. The estimated odds ratio with a 95% confidence interval was pooled. subgroup analyses and sensitivity analyses were also conducted. We used Begg’s funnel plot and Egger’s test to detect the potential publication bias. Thirteen cohort studies with a total of 19239 patients with stroke were included in this meta-analysis. The heterogeneity among studies was slight (I2 = 59.0%, P = 0.031). The results from a random-effect model suggest that anemia is associated with an increased mortality risk in patients with stroke (adjusted odds ratio = 1.39, 95% confidence interval: 1.22–1.58, P < 0.001). The subgroup analyses are consistent with the total results. This meta-analysis of 13 cohort studies finds that anemia increases the mortality risk in patients with stroke. Future studies should perform longer follow-up to confirm this finding and explore its possible mechanism.
Collapse
|
40
|
Long-Term Mortality and Its Risk Factors in Stroke Survivors. J Stroke Cerebrovasc Dis 2015; 25:635-41. [PMID: 26738815 DOI: 10.1016/j.jstrokecerebrovasdis.2015.11.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 11/18/2015] [Accepted: 11/25/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Stroke is one of the leading causes of mortality worldwide. Understanding the risk factors associated with stroke mortality is important to improve patient management. Few studies have examined long-term mortality and its associated predictive risk factors. METHODS We examined long-term mortality in 1137 patients with acute stroke and compared it to a geographically age- and sex-matched, stroke-free control group. We followed the stroke patients for as long as 16.4 years. In 1018 of these patients we assessed the effect of demographic, clinical, and hematological factors on mortality. RESULTS At the end of the study period, 51.7% of the patients and 32.7% of the stroke-free control individuals had died (hazard ratio 2.2, confidence interval 1.9-2.5, P < .001). A total of 72.5% of the patients and 53% of the controls with 12 years' follow-up (n = 570) had died (P < .001). Regression analyses indicate that, in addition to known risk factors such as age, diabetes, and stroke severity, both low cholesterol (P < .001) and hemoglobin (P < .002), hyperhomocysteinemia (P = .005), and elevated serum creatinine (P < .001) at index stroke are associated with increased long-term mortality. CONCLUSIONS Stroke patients surviving the first year after stroke have a markedly increased mortality rate as seen in long-term follow-up. Furthermore, the results from this study indicate that changes in creatinine, homocysteine, and hemoglobin should be followed more carefully as standard practice after acute stroke.
Collapse
|
41
|
Nkoke C, Lekoubou A, Balti E, Kengne AP. Stroke mortality and its determinants in a resource-limited setting: A prospective cohort study in Yaounde, Cameroon. J Neurol Sci 2015; 358:113-7. [PMID: 26382832 DOI: 10.1016/j.jns.2015.08.033] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/23/2015] [Accepted: 08/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND About three quarters of stroke deaths occur in developing countries including those in sub-Saharan African. Short and long-term stroke fatality data are needed for health service and policy formulation. METHODS We prospectively followed up from stroke onset, 254 patients recruited from the largest reference hospitals in Yaounde (Cameroon). Mortality and determinants were investigated using the accelerated failure time regression analysis. RESULTS Stroke mortality rates at one-, six- and 12 months were respectively 23.2% (Ischemic strokes: 20.4%, hemorrhagic strokes: 26.1%, and undetermined strokes: 34.8, p=0.219), 31.5% (ischemic strokes: 31.5%, hemorrhagic strokes: 30.4%, and undetermined strokes: 34.8%, p=0.927), and 32.7% (ischemic strokes: 32.1%, hemorrhagic strokes: 30.4%, undetermined strokes: 43.5%, p=0.496). Fever, swallowing difficulties, and admission NIHSS independently predicted mortality at one month, six and 12 months. Elevated systolic blood pressure (BP) predicted mortality at one month. Elevated diastolic blood pressure was a predictor of mortality at one month in participants with hemorrhagic stroke. Low hemoglobin level on admission only predicted long term mortality. CONCLUSION In this resource-limited setting, post-stroke mortality was high with 1 out of 5 deaths occurring at one month and up to 30% deaths at six and twelve months after the index event. Fever, stroke severity, elevated BP and anemia increased the risk of death. Our findings add to the body of evidence for the poor outcome after stroke in resource limited environments.
Collapse
Affiliation(s)
- Clovis Nkoke
- Faculty of Medicine and Biomedical Sciences, Department of Internal Medicine, Yaoundé, Cameroon.
| | - Alain Lekoubou
- Medical University of SC, Department of Neurology, Charleston, USA.
| | - Eric Balti
- Faculty of Medicine and Pharmacy, Brussels Free University-VUB, Brussels, Belgium.
| | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council of South Africa, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
42
|
Lasek-Bal A, Holecki M, Stęposz A, Duława J. The impact of anemia on the course and short-term prognosis in patients with first ever ischemic stroke. Neurol Neurochir Pol 2015; 49:107-12. [PMID: 25890925 DOI: 10.1016/j.pjnns.2015.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 02/02/2015] [Accepted: 03/03/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Anemia is the risk factor for cerebrovascular events. The aim of this study was to evaluate the prevalence of anemia among patients with first-ever stroke and its impact on neurological state in the acute phase of the disease and the degree of disability in short-term follow-up. PATIENTS AND METHODS The prospective study included 107 patients aged 72.81 ± 11.12 with the first-ever stroke. Each patient underwent CT of the head and blood tests, including Hb concentration on the first day of hospitalization. We have analyzed the neurological state on the first day of stroke by NIHSS and the functional status on the 14th day after the onset of stroke by mRankin scale in patients with and without anemia. Patients with anemia were additionally divided according to Hb level (less or over 11g/dl). RESULTS Patients with Hb≤ 11g/dl significantly more often achieved a score of 4-5 points on mRankin scale on the 14th day of stroke compared to patients with anemia and Hb>11g/dl. Independent predictors of a worse functional status on the 14th day of stroke in patients with anemia include the neurological state on the 1st day and the hemispheric location of stroke; an independent predictor of death was the neurological state on the 1st day of onset. CONCLUSION Mild anemia did not influence significantly the neurological condition in acute phase of stroke but worsened the functional status in subacute phase of stroke. The neurological state on the first day of stroke and the hemispheric location of cerebral ischemia are independent factors of poor prognosis in patients with anemia in short-term follow-up.
Collapse
Affiliation(s)
- Anetta Lasek-Bal
- Department of Neurology, Medical University of Silesia Hospital No. 7, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland.
| | - Michał Holecki
- Department of Internal Medicine and Metabolic Diseases, Medical University of Silesia Hospital No. 7, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
| | - Arkadiusz Stęposz
- Department of Neurology, Medical University of Silesia Hospital No. 7, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
| | - Jan Duława
- Department of Internal Medicine and Metabolic Diseases, Medical University of Silesia Hospital No. 7, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
| |
Collapse
|
43
|
Fuster D, Sanvisens A, Bolao F, Zuluaga P, Rivas I, Tor J, Muga R. Markers of inflammation and mortality in a cohort of patients with alcohol dependence. Medicine (Baltimore) 2015; 94:e607. [PMID: 25761182 PMCID: PMC4602466 DOI: 10.1097/md.0000000000000607] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Inflammation and intestinal permeability are believed to be paramount features in the development of alcohol-related liver damage. We aimed to assess the impact of 3 surrogate markers of inflammation (anemia, fibrinogen, and ferritin levels) on mid-term mortality of patients with alcohol dependence. This longitudinal study included patients with alcohol dependence admitted for hospital detoxification between 2000 and 2010. Mortality was ascertained from clinical charts and the mortality register. Associations between markers of inflammation and all-cause mortality were analyzed with mortality rates and Cox proportional hazards regression models. We also performed a subgroup analysis of mortality rates in patients with anemia, based on their mean corpuscular volume (MCV). We included 909 consecutive patients with alcohol dependence. Patients were mostly male (80.3%), had a median age of 44 years (interquartile range [IQR]: 38-50), and upon admission, their median alcohol consumption was 192 g/day (IQR: 120-265). At admission, 182 (20.5%) patients had anemia; 210 (25.9%) had fibrinogen levels >4.5 mg/dL; and 365 (49.5%) had ferritin levels >200 ng/mL. At the end of follow-up (median 3.8 years [IQR: 1.8-6.5], and a total of 3861.07 person-years), 118 patients had died (12.9% of the study population). Cox regression models showed that the presence of anemia at baseline was associated with mortality (hazard ratio [HR]: 1.67, 95% confidence interval [CI]: 1.11-2.52, P < 0.01); no associations were found between mortality and high fibrinogen or high ferritin levels. A subgroup of patients with anemia was analyzed and compared to a control group of patients without anemia and a normal MCV. The mortality ratios of patients with normocytic and macrocytic anemia were 3.25 (95% CI: 1.41-7.26; P < 0.01) and 3.39 (95% CI: 1.86-6.43; P < 0.01), respectively. Patients with alcohol dependence admitted for detoxification had an increased risk of death when anemia was present at admission. More accurate markers of systemic inflammation are needed to serve as prognostic factors for poor outcomes in this subset of patients.
Collapse
Affiliation(s)
- Daniel Fuster
- From the Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain (DF, AS, PZ, JT, RM); Department of Internal Medicine, Hospital Universitari de Bellvitge, Universitat de Barcelona, L'Hospitalet de Llobregat, Spain (FB); and Municipal Centre for Substance Abuse Treatment (Centro Delta), IMSP Badalona, Badalona, Spain (IR)
| | | | | | | | | | | | | |
Collapse
|
44
|
Milionis H, Papavasileiou V, Eskandari A, D'Ambrogio-Remillard S, Ntaios G, Michel P. Anemia on admission predicts short- and long-term outcomes in patients with acute ischemic stroke. Int J Stroke 2014; 10:224-30. [PMID: 25427291 DOI: 10.1111/ijs.12397] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 08/05/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND It is still debatable whether anemia predicts stroke outcome. AIM To describe the characteristics of patients with acute ischemic stroke (AIS) and anemia and identify whether hemoglobin status on admission is a prognostic factor of AIS outcome. METHODS All 2439 patients of the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) between January 2003 and June 2011 were selected. Demographics, risk factors, prestroke treatment, clinical, radiological and metabolic variables in patients with and without anemia according to the definition of the World Health Organization were compared. Functional disability and mortality were recorded up to 12 months from admission. RESULTS Anemic patients (17.5%) were older, had lower body mass index, higher rates of coronary artery disease (CAD), atrial fibrillation, diabetes mellitus and peripheral artery disease. Anemia was associated with more severe stroke manifestations, lower systolic and diastolic blood pressure measurements, worse estimated glomerular filtration rate and elevated C-reactive protein concentrations upon admission and with increased modified Rankin scores during the follow-up. Anemic patients had higher 7-day, 3-month and 12-month mortality, which was associated with hemoglobin status and other factors, including age, CAD, stroke severity, and baseline C-reactive levels. Hemoglobin levels were inversely associated with recurrent stroke and mortality throughout the 12-month follow-up. CONCLUSION Anemia is common among AIS patients and is associated with cardiovascular comorbidities. Low hemoglobin status independently predicts short and long-term mortality.
Collapse
Affiliation(s)
- Haralampos Milionis
- Neurology Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland; Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | | | | | | | | | | |
Collapse
|
45
|
Luvizutto GJ, Monteiro TA, Braga GP, Bazan SGZ, Resende LADL, Bazan R. Low haemoglobin levels increase unilateral spatial neglect in acute phase of stroke. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:757-61. [DOI: 10.1590/0004-282x20140112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 07/11/2014] [Indexed: 11/21/2022]
Abstract
Objective The objective of this study was to evaluate the relationship between unilateral spatial neglect (USN) and haemoglobin (Hb) level in acute phase of stroke. Method Cross-sectional study was performed after right hemisphere ischemic stroke. Independent variable: Hb level (mg/dL); Outcome: USN; Potential confounding factors: Age, National Institutes of Health Stroke Scale (NIHSS), and glycaemia (mg/dL); Characterization variables were obtained from electronic medical records, Hb, mean corpuscular volume (MCV) and glycaemia by laboratory exams, and USN by cancellation and bisection tasks. The relationship between Hb and USN was assessed by Spearman correlation and linear regression model. Results 40 individuals were evaluated; it was observed that the higher the Hb level, the better the USN test performance, with the two being negatively correlated. There was no significant correlation between VCM level and USN performance. Conclusion Low hemoglobin levels may indicate a worse performance in USN cancellation and bissection tests in acute phase of stroke.
Collapse
Affiliation(s)
| | | | | | | | | | - Rodrigo Bazan
- Universidade Estadual Paulista “Júlio de Mesquita Filho”, Brazil
| |
Collapse
|
46
|
Chang YL, Hung SH, Ling W, Lin HC, Li HC, Chung SD. Association between ischemic stroke and iron-deficiency anemia: a population-based study. PLoS One 2013; 8:e82952. [PMID: 24349404 PMCID: PMC3857285 DOI: 10.1371/journal.pone.0082952] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 10/30/2013] [Indexed: 11/19/2022] Open
Abstract
Background Very little is known about the relationship between non-sickle cell anemia and stroke. The purpose of this study is to evaluate the association of iron-deficiency anemia (IDA) with stroke based on a nationwide coverage database in Taiwan. Methods The case-control study subjects were obtained from the Taiwanese Longitudinal Health Insurance Database 2000. We included 51,093 subjects with stroke as cases and randomly selected 153,279 controls (3 controls per case) in this study.Separate conditional logistic regression analyses were used to calculate the odds ratio (OR) for having been previously diagnosed with IDA between cases and controls.We further analyzed the association between stroke and IDA by stroke subtype. Results Results showed that 3,685 study subjects (1.81%) had been diagnosed with IDA prior to the index date; of those subjects, 1,268 (2.48%) were cases and 2,417 (1.58%) were controls (p<0.001). Conditional logistic regression shows that the OR of having previously received an IDA diagnosis among cases was 1.49 (95% CI: 1.39~1.60; p < 0.01) that of controls after adjusting for monthly income, geographic region, hypertension, diabetes, coronary heart disease, atrial fibrillation, heart failure, hyperlipidemia, tobacco use disorder, and alcohol abuse/alcohol dependency syndrome. Furthermore, the adjusted OR of prior IDA for cases with ischemic stroke was found to be 1.45 (95% CI: 1.34~1.58) compared to controls. However, we did not find any significant relationship between IDA and subarachnoid/intracerebral hemorrhage even adjusting for other confounding factors (OR=1.17, 95% CI=0.97~1.40). Conclusion There is a significant association between prior IDA and ischemic stroke.
Collapse
Affiliation(s)
- Yen-Liang Chang
- Department of Otolaryngology Head and Neck Surgery, Cathay General Hospital, Taipei, Taiwan
- School of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
| | - Shih-Han Hung
- Department of Otolaryngology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Wells Ling
- Department of Psychology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Herng-Ching Lin
- Sleep Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Hsien-Chang Li
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Shiu-Dong Chung
- Sleep Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- * E-mail:
| |
Collapse
|
47
|
Lelubre C, Salomez F, Taccone FS. Quelles cibles d’hémoglobine pour les pathologies cérébrales ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0728-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
48
|
Abstract
PURPOSE OF REVIEW Anaemia is common among patients in the neurocritical care unit (NCCU) and is thought to exacerbate brain injury. However, the optimal haemoglobin (Hgb) level still remains to be elucidated for traumatic brain injury (TBI), subarachnoid haemorrhage (SAH) and acute ischaemic stroke (AIS). This review outlines recent studies about anaemia and the effects of red blood cell transfusion (RBCT) on outcome in TBI, SAH and AIS patients admitted to the NCCU. RECENT FINDINGS Patients with severe SAH, AIS and TBI often develop anaemia and require RBCT. In general critical care, a restrictive RBCT strategy (Hgb ~7 g/dl) is preferable in patients without serious cardiac disease. In severe TBI, AIS and SAH, both anaemia and RBCT may negatively influence clinical outcome. However, the appropriate RBCT trigger remains unclear and there is great variance in how these patients are transfused. There is evidence from PET and microdialysis studies in humans that RBCT can favourably influence brain metabolism and oxygenation. This correction of hypoxia or altered metabolism rather than anaemia may be of greater importance. SUMMARY Results from general critical care should not be extrapolated to all patients with acute brain injury. Transfusion is not risk free, but RBCT use needs to be considered also in terms of potential benefit.
Collapse
Affiliation(s)
- Peter LeRoux
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA 191406, USA.
| |
Collapse
|
49
|
Murray AM, Seliger S, Lakshminarayan K, Herzog CA, Solid CA. Incidence of stroke before and after dialysis initiation in older patients. J Am Soc Nephrol 2013; 24:1166-73. [PMID: 23620399 DOI: 10.1681/asn.2012080841] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The incidence of stroke is substantially higher among hemodialysis patients than among patients with earlier stages of CKD, but to what extent the initiation of dialysis accelerates the risk for stroke is not well understood. In this cohort study, we analyzed data from incident hemodialysis and peritoneal dialysis patients in 2009 who were at least 67 years old and had Medicare as primary payer. We noted whether each of the 20,979 hemodialysis patients initiated dialysis as an outpatient (47%) or inpatient (53%). One year before initiation, the baseline stroke rate was 0.15%-0.20% of patients per month (ppm) for both outpatient and inpatient initiators. Among outpatient initiators, stroke rates began rising approximately 90 days before initiation, reached 0.5% ppm during the 30 days before initiation, and peaked at 0.7% ppm (8.4% per patient-year) during the 30 days after initiation. The pattern was similar among inpatient initiators, but the stroke rate peaked at 1.5% ppm (18% per patient-year). For both hemodialysis groups, stroke rates rapidly declined by 1-2 months after initiation, fluctuated, and stabilized at approximately twice the baseline rate by 1 year. Among the 620 peritoneal dialysis patients, stroke rates were slightly lower and variable, but approximately doubled after initiation. In conclusion, these data suggest that the process of initiating dialysis may cause strokes. Further studies should evaluate methods to mitigate the risk for stroke during this high-risk period.
Collapse
Affiliation(s)
- Anne M Murray
- Divisions of Geriatrics, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.
| | | | | | | | | |
Collapse
|
50
|
Hare GM, Tsui AK, Ozawa S, Shander A. Anaemia: Can we define haemoglobin thresholds for impaired oxygen homeostasis and suggest new strategies for treatment? Best Pract Res Clin Anaesthesiol 2013; 27:85-98. [DOI: 10.1016/j.bpa.2012.12.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 12/17/2012] [Indexed: 12/30/2022]
|