1
|
van Bohemen SJ, Rogers JM, Alavanja A, Evans A, Young N, Boughton PC, Valderrama JT, Kyme AZ. Safety, feasibility, and acceptability of a novel device to monitor ischaemic stroke patients. J Med Eng Technol 2024:1-13. [PMID: 39400105 DOI: 10.1080/03091902.2024.2409115] [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: 08/03/2023] [Revised: 09/16/2024] [Accepted: 09/22/2024] [Indexed: 10/15/2024]
Abstract
This study assessed the safety, feasibility, and acceptability of a novel device to monitor ischaemic stroke patients. The device captured electroencephalography (EEG) and electrocardiography (ECG) data to compute an ECG-based metric, termed the Electrocardiography Brain Perfusion index (EBPi), which may function as a proxy for cerebral blood flow (CBF). Seventeen ischaemic stroke patients wore the device for nine hours and reported feedback at 1, 3, 6 and 9 h regarding user experience, comfort, and satisfaction (acceptability). Safety was assessed as the number of adverse events reported. Feasibility was assessed as the percentage of uninterrupted EEG/ECG data recorded (data capture efficiency). No adverse events were reported, only minor incidences of discomfort. Overall device comfort (mean ± 1 standard deviation (SD) (range)) (92.5% ± 10.3% (57.0-100%)) and data capture efficiency (mean ± 1 SD (range)) (95.8% ± 6.8% (54.8-100%)) were very high with relatively low variance. The device didn't restrict participants from receiving clinical care and rarely (n = 6) restricted participants from undertaking routine tasks. This study provides a promising evidence base for the deployment of the device in a clinical setting. If clinically validated, EBPi may be able to detect CBF changes to monitor early neurological deterioration and treatment outcomes, thus filling an important gap in current monitoring options.TRIAL REGISTRATION: The study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000112763).
Collapse
Affiliation(s)
| | - Jeffrey M Rogers
- Department of Clinical Medicine, Macquarie University, Sydney, Australia
- Neurocare Group, Sydney, Australia
| | | | - Andrew Evans
- Department of Aged Care of Stroke, Westmead Hospital, Sydney, Australia
| | - Noel Young
- Imaging, Western Sydney University, Sydney, Australia
| | - Philip C Boughton
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Spine Institute, Sydney, Australia
| | - Joaquin T Valderrama
- Department of Signal Theory, Telematics and Communications, University of Granada, Granada, Spain
- Research Centre for Information and Communications Technologies (CITIC-UGR), University of Granada, Granada, Spain
- Department of Linguistics, Macquarie University, Sydney, Australia
| | - Andre Z Kyme
- School of Biomedical Engineering, The University of Sydney, Sydney, Australia
- Brain and Mind Centre, The University of Sydney, Sydney, Australia
| |
Collapse
|
2
|
Hou Z, Ma M, Ding D, Zhang L, Wang D. Association of perfusion variables with functional outcome in acute mild ischemic stroke patients or transient ischemic attack. J Stroke Cerebrovasc Dis 2024; 33:107983. [PMID: 39251044 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107983] [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: 03/04/2024] [Revised: 08/12/2024] [Accepted: 08/28/2024] [Indexed: 09/11/2024] Open
Abstract
OBJECTIVE Some patients with acute minor stroke or transient ischemic attack (TIA) are at risk for a poor prognosis. There are a limited number of studies that have investigated the functional prognosis of acute mild ischemic stroke or TIA based on imaging indicators. This study aims to explore the relationship between Perfusion Variables and poor prognosis in patients with mild ischemic stroke or TIA. MATERIALS AND METHODS A retrospective analysis was conducted on a cohort of 344 patients with mild ischemic stroke or TIA, who were admitted and treated at the First Affiliated Hospital of Soochow University between January 2016 and March 2022. The criteria were National Institutes of Health Stroke Scale (NIHSS) scores of ≤5. Poor outcome was defined as a modified Rankin Scale (mRS) score of ≥2 points at 90 days. Multivariate logistic regression was performed to identify the risk factors associated with clinical outcomes. The receiver operating characteristic (ROC) analysis was used to explore the cutoff value of factors. RESULTS Following a 3-month follow-up period, 49 (12.4 %) out of the 344 patients with mild stroke or TIA demonstrated a poor prognosis. Multivariable regression analysis identified mismatch volume as independent predictors of a poor 90-day prognosis. The ROC curve analysis indicated that a mismatch volume exceeding 16.5 ml was associated with a higher risk of unfavorable functional outcomes. CONCLUSION A mismatch volume of ≥16.5mL predicted poor functional outcome in mild stroke or TIA patients.
Collapse
Affiliation(s)
- Zhangyan Hou
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Mingwei Ma
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Dongxue Ding
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China.
| | - Lulu Zhang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Dapeng Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| |
Collapse
|
3
|
Huang X, Ye Q, Zhu Z, Chen Y, Xia N, Chen R, Geng W, Ye Z. Variants in 3p24.3 predicts the risk of early neurological deterioration in large artery atherosclerotic stroke. Brain Res 2024; 1833:148867. [PMID: 38499234 DOI: 10.1016/j.brainres.2024.148867] [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: 12/18/2023] [Revised: 02/19/2024] [Accepted: 03/14/2024] [Indexed: 03/20/2024]
Abstract
The rate of early neurological deterioration (END) differs in different subtypes of ischaemic stroke. Previous studies showed PLCL2 gene is a novel susceptibility locus for the occurrence of atherosclerosis and thrombotic events. The objective of this research is to examine the efficacy that PLCL2 may have on the risk of END in large artery atherosclerotic (LAA) stroke. Tagged single nucleotide polymorphisms (SNPs) were identified by a strategy of fine-mapping. The genotyping of the selected SNPs was performed by SNPscan. The impact of PLCL2 on indicating the susceptibility of END in LAA patients was evaluated by binary logistic regression. The SNP-SNP interactions of PLCL2 for END was assessed by generalized multifactor dimensionality reduction (GMDR). A total of 1527 LAA stroke patients were recruited, 582 patients (38 %) experienced END. Compared to participants without END, participants experienced END were much older (P = 0.018), more likely to suffer pre-existing diabetes mellitus (P = 0.036), higher frequent in active tobacco users (P = 0.022) and had much higher median NIHSS on admission (P < 0.001). Rs4685423 was identified to be a predictor to the risk of END: the frequency of END in AA genotype patients is lower than that in AC or CC genotype patients (multivariate-adjusted, OR 0.63; 95 % CI 0.49-0.80; P < 0.001). The SNP-SNP interactions analysis indicates rs4685423 has the greatest impacton the risk of END for LAA patients. The time from admission diagnosis to END onset in AA genotype patients is much later than that in CA or CC genotype patients (log-rank, P = 0.005). In summary, the PLCL2 rs4685423 SNP is probably associated with the END risk in LAA stroke patients.
Collapse
Affiliation(s)
- Xiaoya Huang
- Department of Neurology, Wenzhou Central Hospital & Dingli Clinical Institute of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Qiang Ye
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Zhenguo Zhu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Yanyan Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Niange Xia
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Rongrong Chen
- Department of Neurology, Wenzhou Central Hospital & Dingli Clinical Institute of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Wujun Geng
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China; Wenzhou Key Laboratory of Perioperative Medicine, Wenzhou, Zhejiang, PR China.
| | - Zusen Ye
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China; Wenzhou Key Laboratory of Perioperative Medicine, Wenzhou, Zhejiang, PR China.
| |
Collapse
|
4
|
Jin M, Peng Q, Wang Y. Post-thrombolysis early neurological deterioration occurs with or without hemorrhagic transformation in acute cerebral infarction: risk factors, prediction model and prognosis. Heliyon 2023; 9:e15620. [PMID: 37144189 PMCID: PMC10151352 DOI: 10.1016/j.heliyon.2023.e15620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/25/2023] [Accepted: 04/17/2023] [Indexed: 05/06/2023] Open
Abstract
Objectives Early neurological deterioration (END) after ischemic stroke is a severe clinical event and can be caused by hemorrhagic and ischemic injury. We studied the difference between the risk factors of END occurs with or without hemorrhagic transformation after intravenous thrombolysis. Materials and methods Consecutive cerebral infarction patients who underwent intravenous thrombolysis from 2017 to 2020 in our hospital were retrospectively recruited. END was defined as a ≥2 points increase on 24-h National Institutes of Health Stroke Scale (NIHSS) score after therapy compared with the best neurological status after thrombolysis and divided into two types based on the computed tomography (CT): symptomatic intracranial hemorrhage (ENDh) and non-hemorrhagic factors (ENDn). Potential risk factors of ENDh and ENDn were assessed by multiple logistic regression and applied to establish the prediction model. Results A total of 195 patients were included. In multivariate analysis, the previous history of cerebral infarction (odds ratio [OR],15.19; 95% confidence interval [CI],1.43-161.17; P = 0.025), previous history of atrial fibrillation (OR,8.43; 95%CI,1.09-65.44; P = 0.043), higher baseline NIHSS score (OR,1.19; 95%CI,1.03-1.39; P = 0.022) and higher alanine transferase level (OR,1.05; 95%CI, 1.01-1.10; P = 0.016) were independently associated with ENDh. While higher systolic blood pressure (OR,1.03; 95%CI,1.01-1.05; P = 0.004), higher baseline NIHSS score (OR,1.13; 95%CI,2.86-27.43; P < 0.000) and large artery occlusion (OR,8.85, 95%CI,2.86-27.43; P < 0.000) were independent risk factors of ENDn. The prediction model showed good specificity and sensitivity in predicting the risk of ENDn. Conclusions There are differences between the major contributors to ENDh and ENDn, while a severe stroke can increase the occurrence of both sides.
Collapse
Affiliation(s)
- Mengzhi Jin
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang University
| | - Qingxia Peng
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yidong Wang
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat‑Sen Memorial Hospital, Sun Yat-Sen University
- Guangdong Province Key Laboratory of Brain Function and Disease, Zhongshan School of Medicine, Sun Yat-Sen University
- Corresponding author. No. 107 Yan Jiang Road West, Guangzhou 510120, Guangdong Province, China.
| |
Collapse
|
5
|
Pan L, Tang WD, Wang K, Fang QF, Liu MR, Wu ZX, Wang Y, Cui SL, Hu G, Hou TJ, Hu WW, Chen Z, Zhang XN. Novel Caspase-1 inhibitor CZL80 improves neurological function in mice after progressive ischemic stroke within a long therapeutic time-window. Acta Pharmacol Sin 2022; 43:2817-2827. [PMID: 35501362 PMCID: PMC9622895 DOI: 10.1038/s41401-022-00913-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/16/2022] [Indexed: 11/09/2022] Open
Abstract
Progressive ischemic stroke (PIS) is featured by progressive neurological dysfunction after ischemia. Ischemia-evoked neuroinflammation is implicated in the progressive brain injury after cerebral ischemia, while Caspase-1, an active component of inflammasome, exaggerates ischemic brain injury. Current Caspase-1 inhibitors are inadequate in safety and druggability. Here, we investigated the efficacy of CZL80, a novel Caspase-1 inhibitor, in mice with PIS. Mice and Caspase-1-/- mice were subjected to photothrombotic (PT)-induced cerebral ischemia. CZL80 (10, 30 mg·kg-1·d-1, i.p.) was administered for one week after PT onset. The transient and the progressive neurological dysfunction (as foot faults in the grid-walking task and forelimb symmetry in the cylinder task) was assessed on Day1 and Day4-7, respectively, after PT onset. Treatment with CZL80 (30 mg/kg) during Day1-7 significantly reduced the progressive, but not the transient neurological dysfunction. Furthermore, we showed that CZL80 administered on Day4-7, when the progressive neurological dysfunction occurred, produced significant beneficial effects against PIS, suggesting an extended therapeutic time-window. CZL80 administration could improve the neurological function even as late as Day43 after PT. In Caspase-1-/- mice with PIS, the beneficial effects of CZL80 were abolished. We found that Caspase-1 was upregulated during Day4-7 after PT and predominantly located in activated microglia, which was coincided with the progressive neurological deficits, and attenuated by CZL80. We showed that CZL80 administration did not reduce the infarct volume, but significantly suppressed microglia activation in the peri-infarct cortex, suggesting the involvement of microglial inflammasome in the pathology of PIS. Taken together, this study demonstrates that Caspase-1 is required for the progressive neurological dysfunction in PIS. CZL80 is a promising drug to promote the neurological recovery in PIS by inhibiting Caspase-1 within a long therapeutic time-window.
Collapse
Affiliation(s)
- Ling Pan
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Wei-Dong Tang
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Ke Wang
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Qi-Feng Fang
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Meng-Ru Liu
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Zhan-Xun Wu
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Yi Wang
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Sun-Liang Cui
- Department of Pharmachemistry, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Gang Hu
- Department of Pharmacology, School of Medicine and Life Sciences, Nanjing University of Chinese Medicine, Nanjing, 210029, China
| | - Ting-Jun Hou
- Department of Pharmachemistry, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Wei-Wei Hu
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Zhong Chen
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China.
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China.
| | - Xiang-Nan Zhang
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China.
| |
Collapse
|
6
|
Xia H, Wang Z, Tian M, Liu Z, Zhou Z. Low-Molecular-Weight Heparin Versus Aspirin in Early Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Immunol 2022; 13:823391. [PMID: 35281068 PMCID: PMC8908308 DOI: 10.3389/fimmu.2022.823391] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives To evaluate the difference between low-molecular-weight heparin (LMWH) and aspirin in preventing early neurological deterioration (END) and recurrent ischemic stroke (RIS), post-recovery independence, and safety outcomes in acute ischemic stroke. Materials and Methods We performed systematic searches of the PubMed, Embase, Web of Science, and Cochrane Library databases for full-text articles of randomized controlled trials (RCTs) of LMWH vs. aspirin in the early management of acute ischemic stroke. Information on study design, eligibility criteria, baseline information, and outcomes was extracted. Synthesized relative risks (RRs) with 95% confidence intervals (CIs) are used to present the differences between the two treatments based on fixed-effects models. Results Five RCTs were retrieved from the online databases. The results showed no significant difference in efficacy outcomes between the two groups among unselected patients. Subgroup analysis showed that LMWH was significantly related to a lower incidence of END events [relative risk (RR): 0.44, 95% confidence interval (CI): 0.35-0.56] and reduced occurrence of RIS during treatment (OR: 0.34, 95% CI: 0.16-0.75) in non-cardioembolic stroke. LMWH significantly increased the number of patients with a modified Rankin scale (mRS) score of 0-1 at 6 months in patients with large-artery occlusive disease (LAOD) (RR: 0.50, 95% CI: 0.27-0.91). LMWH had a similar effect on symptomatic intracranial hemorrhage (sICH) and major extracranial hemorrhage during treatment to that of aspirin, except that LMWH was related to an increased likelihood of extracranial hemorrhage. Conclusions In patients with acute non-cardioembolic ischemic stroke, especially that with large-artery stenosis, LMWH treatment significantly reduced the incidence of END and RIS, and improved the likelihood of independence (mRS 0-1) at 6 months compared with those with aspirin treatment. LMWH was related to an increased likelihood of extracranial hemorrhage among all patients; however, the difference in major extracranial hemorrhage and sICH was not significant. Choosing the appropriate patients and paying attention to the start time and duration of treatment are very important in the use of anticoagulation. Systematic Review Registration http://www.crd.york.ac.uk/PROSPERO, identifier CRD42020185446.
Collapse
Affiliation(s)
- Hui Xia
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Ziyao Wang
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Min Tian
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Zunjing Liu
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Zhenhua Zhou
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| |
Collapse
|
7
|
Sabir Rashid A, Huang-Link Y, Johnsson M, Wetterhäll S, Gauffin H. Predictors of Early Neurological Deterioration and Functional Outcome in Acute Ischemic Stroke: The Importance of Large Artery Disease, Hyperglycemia and Inflammatory Blood Biomarkers. Neuropsychiatr Dis Treat 2022; 18:1993-2002. [PMID: 36097537 PMCID: PMC9464020 DOI: 10.2147/ndt.s365758] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early neurological deterioration (END) in acute ischemic stroke (AIS) can be associated with poor outcome. The aim of this study was to investigate the association between infarction subtypes, biomarkers and END, and to identify patients with risk of unfavorable functional outcome. MATERIALS AND METHODS This prospective study enrolled 101 patients with AIS. Neurological status was evaluated according to NIHSS at acute onset, on days 2, 3, and 90. END was defined as ≥2-point increase of NIHSS within 72 hours. Functional outcome was assessed using NIHSS and the modified Rankin Scale (mRS) at day 90. RESULTS END was observed in 20, 8%. Patients with large artery disease had higher risk of developing END compared with patients with cardioembolism or small vessel disease (p <0.01). Significant higher blood glucose level and leukocytes were observed in the END group. Patients with END had higher scores of mRS at day 90 (p <0.01). Levels of NSE, IL-6, hsCRP and NT-proBNP were higher in the patients with unfavorable compared with favorable functional outcome. CONCLUSION Large artery disease, high blood glucose and leukocytes levels are associated with END. Elevated levels of blood markers NSE, IL-6, HsCRP and NT-proBNP indicate poor functional outcome at 90 days after AIS. These patients must be identified and be offered treatment immediately in order to improve the functional outcome after AIS.
Collapse
Affiliation(s)
- Avan Sabir Rashid
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Yumin Huang-Link
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Marcus Johnsson
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Simon Wetterhäll
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Helena Gauffin
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| |
Collapse
|
8
|
Gwak DS, Kwon JA, Shim DH, Kim YW, Hwang YH. Perfusion and Diffusion Variables Predict Early Neurological Deterioration in Minor Stroke and Large Vessel Occlusion. J Stroke 2021; 23:61-68. [PMID: 33600703 PMCID: PMC7900396 DOI: 10.5853/jos.2020.01466] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/01/2020] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose Patients with acute large vessel occlusion (LVO) presenting with mild stroke symptoms are at risk of early neurological deterioration (END). This study aimed to identify the optimal imaging variables for predicting END in this population.
Methods We retrospectively analyzed 94 patients from the prospectively maintained institutional stroke registry admitted between January 2011 and May 2019, presenting within 24 hours after onset, with a baseline National Institutes of Health Stroke Scale score ≤5 and anterior circulation LVO. Patients who underwent endovascular therapy before END were excluded. Volumes of Tmax delay (at >2, >4, >6, >8, and >10 seconds), mismatch (Tmax >4 seconds – diffusion-weighted imaging [DWI] and Tmax >6 seconds – DWI), and mild hypoperfusion lesions (Tmax 2–6 and 4–6 seconds) were measured. The association of each variable with END was examined using receiver operating characteristic curves. The variables with best predictive performance were dichotomized at the cutoff point maximizing Youden’s index and subsequently analyzed using multivariable logistic regression.
Results END occurred in 39.4% of the participants. The optimal variables were identified as Tmax >6 seconds, Tmax >6 seconds – DWI, and Tmax 4–6 seconds with cut-off points of 53.73, 32.77, and 55.20 mL, respectively. These variables were independently associated with END (adjusted odds ratio [aOR], 12.78 [95% confidence interval (CI), 3.36 to 48.65]; aOR, 5.73 [95% CI, 2.04 to 16.08]; and aOR, 9.13 [95% CI, 2.76 to 30.17], respectively).
Conclusions Tmax >6 seconds, Tmax >6 seconds – DWI, and Tmax 4–6 seconds could identify patients at high risk of END following minor stroke due to LVO.
Collapse
Affiliation(s)
- Dong-Seok Gwak
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea
| | - Jung-A Kwon
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea
| | - Dong-Hyun Shim
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea
| | - Yong-Won Kim
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| |
Collapse
|
9
|
Yu WM, Abdul-Rahim AH, Cameron AC, Kõrv J, Sevcik P, Toni D, Lees KR, Wahlgren N, Ahmed N, Caso V, Roffe C, Kobayashi A, Tsivgoulis G, Toni D, Ford G, Lees K, Ringleb P. The Incidence and Associated Factors of Early Neurological Deterioration After Thrombolysis. Stroke 2020; 51:2705-2714. [DOI: 10.1161/strokeaha.119.028287] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background and purpose:
Early neurological deterioration (END) after stroke onset may predict severe outcomes. Estimated rates of END after intravenous thrombolysis among small patient samples have been reported up to 29.8%. We studied the incidence and factors associated with END among patients following intravenous thrombolysis.
Methods:
We analyzed SITS-International Stroke Thrombolysis registry patients with known outcomes enrolled in 2010 to 2017. END was defined as an increase in National Institutes of Health Stroke Scale score ≥4 or death within 24 hours from baseline National Institutes of Health Stroke Scale. We determined the incidence of END and used logistic regression models to inspect its associated factors. We adjusted for variables found significant in univariate analyses (
P
<0.05). Main outcomes were incidence of END, associated predictors of END, ordinal day-90 mRS, and day-90 mortality.
Results:
We excluded 53 539 patients and included 50 726 patients. The incidence of END was 3415/50 726 (6.7% [95% CI, 6.5%–7.0%]). Factors independently associated with END on multivariate analysis were intracerebral hemorrhage (OR, 3.23 [95% CI, 2.96–3.54],
P
<0.001), large vessel disease (LVD) with carotid stenosis (OR, 2.97 [95% CI, 2.45–3.61],
P
<0.001), other LVD (OR, 2.41 [95% CI, 2.03–2.88],
P
<0.001), and ischemic stroke versus transient ischemic attack (TIA)/stroke mimics (OR, 16.14 [95% CI, 3.99–65.3],
P
<0.001). END was associated with worse outcome on ordinal mRS: adjusted OR 2.48 (95% CI, 2.39–2.57,
P
<0.001) by day-90 compared with no END. The adjusted OR for day-90 mortality was 9.70 (95% CI, 8.36–11.26,
P
<0.001).
Conclusions:
The routinely observed rate of END reflected by real-world data is low, but END greatly increases risk of disability and mortality. Readily identifiable factors predict END and may help with understanding causal mechanisms to assist prevention of END.
Collapse
Affiliation(s)
- Wai M. Yu
- Institute of Cardiovascular and Medical Sciences (W.M.Y., A.C.C.), University of Glasgow, United Kingdom
| | - Azmil H. Abdul-Rahim
- Institute of Neuroscience and Psychology (A.H.A.-R.), University of Glasgow, United Kingdom
| | - Alan C. Cameron
- Institute of Cardiovascular and Medical Sciences (W.M.Y., A.C.C.), University of Glasgow, United Kingdom
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine, University of Tartu, Estonia (J.K.)
| | - Petr Sevcik
- Department of Neurology, Faculty of Medicine in Pilsen-Charles University (P.S.)
- Department of Neurology-University Hospital Pilsen, Plzen, Czech Republic (P.S.)
| | - Danilo Toni
- Department of Human Neurosciences, University La Sapienza, Rome, Italy (D.T.)
| | - Kennedy R. Lees
- School of Medicine, Dentistry and Nursing (K.R.L.), University of Glasgow, United Kingdom
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Park CW, Nam HS, Heo JH, Park HJ, Choi JK, Lee HS, Na HK, Kim YD. Non-vitamin K oral anticoagulants as first-line regimen for acute ischemic stroke with non-valvular atrial fibrillation. J Stroke Cerebrovasc Dis 2020; 29:105025. [PMID: 32807440 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/27/2020] [Accepted: 06/03/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE There are various patterns in determining the choice of the first-line antithrombotic agent for acute stroke with non-valvular atrial fibrillation. We investigated the efficacy and safety of non-vitamin K oral anticoagulants as first-line antithrombotics for patients with acute stroke and non-valvular atrial fibrillation. MATERIALS AND METHODS Patients with non-valvular atrial fibrillation and ischemic stroke or transient ischemic attack within 24 h from stroke onset were included. On the basis of the first regimen used and the regimen within 7 days after admission, the study population was divided into three groups: 1) antiplatelet switched to warfarin (A-W), 2) antiplatelet switched to NOAC (A-N), and 3) NOAC only (N only). We compared the occurrence of early neurologic deterioration, symptomatic intracranial hemorrhage, systemic bleeding, and poor functional outcome at 90 days. RESULTS Of 314 included patients, 164, 53, and 97 were classified into the A-W, A-N, and N only groups, respectively. Early neurologic deterioration was most frequently observed in the A-W group (9.1%), followed by the A-N (5.7%) and N only (1.0%) groups (p = 0.017). Multivariable analysis adjusting for potential confounders demonstrated that the N only group was independently associated with a lower rate of early neurologic deterioration (odds ratio [OR] 0.104, 95% CI 0.013-0.831) or poor functional outcome at 90 days (OR 0.450, 95% CI 0.215-0.940) than the A-W group. However, the rate of symptomatic intracranial hemorrhage or any systemic bleeding event did not differ among the groups. CONCLUSION Using non-vitamin K oral anticoagulants as the first-line regimen for acute ischemic stroke may help prevent early neurologic deterioration without increasing the bleeding risk.
Collapse
Affiliation(s)
- Chan Wook Park
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hyung Jong Park
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Republic of Korea.
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Han Kyu Na
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
11
|
Scoppettuolo P, Gaspard N, Depondt C, Legros B, Ligot N, Naeije G. Epileptic activity in neurological deterioration after ischemic stroke, a continuous EEG study. Clin Neurophysiol 2019; 130:2282-2286. [DOI: 10.1016/j.clinph.2019.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/23/2019] [Accepted: 09/15/2019] [Indexed: 12/13/2022]
|
12
|
Huang YC, Tsai YH, Lee JD, Yang JT, Pan YT. A Novel Neuroimaging Model to Predict Early Neurological Deterioration After Acute Ischemic Stroke. Curr Neurovasc Res 2019; 15:129-137. [PMID: 29766805 PMCID: PMC6350204 DOI: 10.2174/1567202615666180516120022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/12/2018] [Accepted: 04/14/2018] [Indexed: 12/02/2022]
Abstract
Objective: In acute ischemic stroke, early neurological deterioration (END) may occur in up to one-third of patients. However, there is still no satisfying or comprehensive predictive model for all the stroke subtypes. We propose a practical model to predict END using magnetic resonance imaging (MRI). Method: Patients with anterior circulation infarct were recruited and they underwent an MRI within 24 hours of stroke onset. END was defined as an elevation of ≥2 points on the National Institute of Health Stroke Scale (NIHSS) within 72 hours of stroke onset. We examined the relationships of END to individual END models, including: A, infarct swelling; B, small subcortical infarct; C, mis-match; and D, recurrence. Results: There were 163 patients recruited and 43 (26.4%) of them had END. The END models A, B and C significantly predicted END respectively after adjusting for confounding factors (p=0.022, p=0.007 and p<0.001 respectively). In END model D, we examined all imaging predictors of Recur-rence Risk Estimator (RRE) individually and only the “multiple acute infarcts” pattern was signifi-cantly associated with END (p=0.032). When applying END models A, B, C and D, they success-fully predicted END (p<0.001; odds ratio: 17.5[95% confidence interval: 5.1–60.8]), with 93.0% sensitivity, 60.0% specificity, 45.5% positive predictive value and 96.0% negative predictive value. Conclusion: The results demonstrate that the proposed model could predict END in all stroke sub-types of anterior circulation infarction. It provides a practical model for clinical physicians to select high-risk patients for more aggressive treatment to prevent END.
Collapse
Affiliation(s)
- Yen-Chu Huang
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
| | - Yuan-Hsiung Tsai
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
| | - Jen-Tsung Yang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
| | - Yi-Ting Pan
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
| |
Collapse
|
13
|
Progression in acute ischemic stroke: Is widespread atherosclerotic background a risk factor? Turk J Phys Med Rehabil 2017; 64:46-51. [PMID: 31453488 DOI: 10.5606/tftrd.2017.1007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/23/2017] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES In this study, we aimed to investigate the causes and conditions related with progression and outcome of progressive acute ischemic stroke. PATIENTS AND METHODS In this prospective study, a total of 78 acute ischemic stroke patients (32 males, 46 females; mean age 70±12.8 years; range 34 to 95 years) were included between February 2006 and October 2010. The patients were classified into two groups as those with and without progression according to the National Institute of Health Stroke Scale (NIHSS). Risk factors for ischemic stroke, stroke subtypes, and radiological investigations and prognosis were compared between the progressive and non-progressive patients. RESULTS Neurological deterioration occurred in 12 patients (15%). Progressive acute ischemic stroke patients had carotid stenosis compared to non-progressive patients (50% vs 19%), and ischemic cardiac disease (33% vs 6%) more common in the patients with progression. Mortality during hospital stay and long term-outcomes were similar between the groups. CONCLUSION Our study results suggest that widespread atherosclerotic diseases may induce neurological progression.
Collapse
|
14
|
Zhang C, Zhao S, Zang Y, Gu F, Mao S, Feng S, Hu L, Zhang C. The efficacy and safety of Dl-3n-butylphthalide on progressive cerebral infarction: A randomized controlled STROBE study. Medicine (Baltimore) 2017; 96:e7257. [PMID: 28746179 PMCID: PMC5627805 DOI: 10.1097/md.0000000000007257] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Progressive cerebral infarction (PCI) is associated with high rates of mortality and disability. Many studies have shown that Dl-3n-butylphthalide (NBP) is effective against acute ischemic stroke. The administration of NBP can result in an increased number of capillaries in the ischemic region, promote the establishment of collateral circulation, protect the mitochondria, and narrow the infarction area, among other effects. In the present study, we evaluated the efficacy and safety of NBP for the treatment of PCI.Between March 2008 and May 2012, we performed a randomized, double-blind placebo-controlled study including 304 inpatients with PCI. These patients were randomly assigned to the test (152 cases) and control groups (152 cases). The test group received 200 mg of NBP soft capsules orally, 15 minutes before each meal, 3 times daily. The control group received 200 mg of placebo soft capsules orally, 15 minutes before each meal, 3 times daily. Treatment was administered during 21 days. The National Institute of Health Stroke Scale (NIHSS) score was assessed before the treatment and on days 7, 14, 21, and 30 after treatment. The Barthel index (BI) was assessed on the same days and on day 90.In the test group, the NIHSS scores on days 7, 14, 21, and 30 were 14.75 ± 4.85, 11.62 ± 3.49, 8.87 ± 5.17, and 6.38 ± 4.93, respectively. In the control group, they were 16.08 ± 3.76, 13.28 ± 5.02, 11.05 ± 4.25, and 8.43 ± 5.41 (P < .05), respectively. The BI on days 7, 14, 21, 30, and 90 were 51.57 ± 15.11, 61.21 ± 16.39, 70.48 ± 18.21, 76.41 ± 19.02, and 81.10 ± 15.52 for the test group and 46.79 ± 18.42, 55.93 ± 19.12, 64.84 ± 17.67, 70.65 ± 18.54, and 76.54 ± 17.05 for the control group (P < .05), respectively. Adverse events were elevation of alanine aminotransferase and aspartate aminotransferase (P > .05).NBP was useful to improve the outcome of patients with PCI and decreased their disability for activities of daily living. NBP was an efficacious and safe treatment for PCI.
Collapse
Affiliation(s)
- Chenhao Zhang
- Department of Neurology, The Second Hospital of Baoding city
| | - Shuqin Zhao
- Department of Internal Medicine, Hospital Affiliated to Hebei University
| | - Yanjing Zang
- Department of Geriatric, The Second Hospital of Baoding City
| | - Fang Gu
- Fifth Department of Internal Medicine, Baoding Children's Hospital, Baoding
| | - Shufang Mao
- Department of Statistical, Chengde Medical Collage, Chengde, Hebei, China
| | - Shanshan Feng
- Department of Neurology, The Second Hospital of Baoding city
| | - Lei Hu
- Department of Neurology, The Second Hospital of Baoding city
| | - Chunliang Zhang
- Department of Neurology, The Second Hospital of Baoding city
| |
Collapse
|
15
|
Revisiting ‘progressive stroke’: incidence, predictors, pathophysiology, and management of unexplained early neurological deterioration following acute ischemic stroke. J Neurol 2017; 265:216-225. [DOI: 10.1007/s00415-017-8490-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/07/2017] [Accepted: 04/07/2017] [Indexed: 12/22/2022]
|
16
|
Irvine HJ, Battey TW, Ostwaldt AC, Campbell BC, Davis SM, Donnan GA, Sheth KN, Kimberly WT. Early neurological stability predicts adverse outcome after acute ischemic stroke. Int J Stroke 2016; 11:882-889. [PMID: 27334760 DOI: 10.1177/1747493016654484] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Deterioration in the National Institutes of Health Stroke Scale (NIHSS) in the early days after stroke is associated with progressive infarction, brain edema, and/or hemorrhage, leading to worse outcome. Aims We sought to determine whether a stable NIHSS score represents an adverse or favorable course. Methods Brain magnetic resonance images from a research cohort of acute ischemic stroke patients were analyzed. Using NIHSS scores at baseline and follow-up (day 3-5), patients were categorized into early neurological deterioration (ΔNIHSS ≥ 4), early neurological recovery (ΔNIHSS ≤ -4) or early neurological stability (ΔNIHSS between -3 and 3). The association between these categories and volume of infarct growth, volume of swelling, parenchymal hemorrhage, and 3-month modified Rankin Scale score were evaluated. Results Patients with early neurological deterioration or early neurological stability were less likely to be independent (modified Rankin Scale = 0-2) at 3 months compared to those with early neurological recovery ( P < 0.001). Patients with early neurological deterioration or early neurological stability were observed to have significantly greater infarct growth and swelling volumes than those with early neurological recovery ( P = 0.03; P < 0.001, respectively). Brain edema was more common than the other imaging markers investigated and was independently associated with a stable or worsening NIHSS score after adjustment for age, baseline stroke volume, infarct growth volume, presence of parenchymal hemorrhage, and reperfusion ( P < 0.0001). Conclusions Stable NIHSS score in the subacute period after ischemic stroke may not be benign and is associated with tissue injury, including infarct growth and brain edema. Early improvement is considerably more likely to occur in the absence of these factors.
Collapse
Affiliation(s)
- Hannah J Irvine
- 1 Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, USA
| | - Thomas Wk Battey
- 1 Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, USA
| | - Ann-Christin Ostwaldt
- 1 Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, USA
| | - Bruce Cv Campbell
- 2 Department of Medicine and Neurology, University of Melbourne, Parkville, Australia.,3 Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Stephen M Davis
- 2 Department of Medicine and Neurology, University of Melbourne, Parkville, Australia
| | - Geoffrey A Donnan
- 3 Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Kevin N Sheth
- 4 Division of Neurocritical Care and Emergency Neurology, Yale New Haven Hospital, New Haven, USA
| | - W Taylor Kimberly
- 1 Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, USA.,5 J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, USA
| |
Collapse
|
17
|
Siegler JE, Samai A, Semmes E, Martin-Schild S. Early Neurologic Deterioration after Stroke Depends on Vascular Territory and Stroke Etiology. J Stroke 2016; 18:203-10. [PMID: 27283280 PMCID: PMC4901951 DOI: 10.5853/jos.2016.00073] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/08/2016] [Accepted: 05/09/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Early neurologic deterioration (END) occurs in up to one-third of patients with ischemic stroke and is associated with poor outcomes. The purpose of the present study was to determine which stroke etiologies and vascular distributions pose a greater threat of END in stroke patients. METHODS Using a single-center registry of prospectively maintained clinical data, adult ischemic stroke patients admitted (July 2008 to June 2014) within 48 hours of symptom onset were evaluated according to stroke etiology and vascular distribution using diffusion-weighted MRI. Major stroke etiologies were divided into cardioembolic, large vessel, small vessel, other, unknown source, and multiple possible etiologies. END was defined as a worsening of 2 or more points on the National Institutes of Health Stroke Scale during a 24-hour period of hospitalization. Crude and backward stepwise regression models were generated to associate stroke etiology and vascular distribution with END. RESULTS Of the included 961 patients (median age 65 years, 47% female, 72% non-White), 323 (34%) experienced END. Strokes involving the internal carotid artery (ICA) were associated with a threefold higher odds of END in stepwise regression models (OR 3.0, 95% CI 1.4-6.6, P=0.006). Among stroke etiologies, those with unclear mechanisms had the lowest odds of END in the fully adjusted model (OR 0.6, 95% CI 0.4-1.0, P=0.029). CONCLUSIONS In our single-center cohort of patients, ICA infarctions were independently associated with END whereas strokes of unknown etiology were least often associated with END. Larger cohorts are necessary to determine which steps, if any, can be taken to prevent END in these vulnerable populations.
Collapse
|
18
|
Hsu CY, Cheng CY, Tsai YH, Lee JD, Yang JT, Weng HH, Lin LC, Huang YC, Lee M, Lee MH, Wu CY, Lin YH, Hsu HL, Yang HT, Pan YT, Huang YC. Perfusion-diffusion Mismatch Predicts Early Neurological Deterioration in Anterior Circulation Infarction without Thrombolysis. Curr Neurovasc Res 2016; 12:277-82. [PMID: 26044806 PMCID: PMC5403961 DOI: 10.2174/1567202612666150605122536] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/17/2015] [Accepted: 05/20/2015] [Indexed: 12/29/2022]
Abstract
Perfusion-diffusion mismatch in magnetic resonance imaging (MRI) represents the non-core hypoperfused area in acute ischemic stroke. The mismatch has been used to predict clinical response after thrombolysis in acute ischemic stroke, but its role for predicting early neurological deterioration (END) in acute ischemic stroke without thrombolysis has not been clarified yet. In this study, we prospectively recruited 54 patients with acute non-lacunar ischemic stroke in anterior circulation without thrombolysis. All patients received the first perfusion MRI within 24 hours from stroke onset. Target mismatch profile was defined as a perfusion-diffusion mismatch ratio ≥ 1.2. END was defined as an increase of ≥ 4 points in the National Institute of Health Stroke Scale (NIHSS) score within 72 hours. There were 13 (24.1%) patients developing END, which was associated with larger infarct growth (p = 0.002), worse modified Rankin Scale (p = 0.001) and higher mortality rate at 3 months (p = 0.025). Target mismatch profiles measured by Tmax ≥ 4, 5 and 6 seconds were independent predictors for END after correcting initial NIHSS score. Among the 3 Tmax thresholds, target mismatch measured by Tmax ≥ 6 seconds had the highest odd’s ratio in predicting END (p < 0.01, odd’s ratio = 17), with an 80% sensitivity and a 79.5% specificity. In conclusion, perfusion-diffusion mismatch could identify the patients at high risk of early clinical worsening in acute ischemic stroke without thrombolysis.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Yen-Chu Huang
- Department of Neurology, Chang Gung Memorial Hospital, 6 West Chia-Pu Road, Putz City, Chiayi County, Taiwan.
| |
Collapse
|
19
|
Siegler JE, Albright KC, George AJ, Boehme AK, Gillette MA, Kumar AD, Aswani M, Martin-Schild S. Time to Neurological Deterioration in Ischemic Stroke. ACTA ACUST UNITED AC 2016; 4:18-24. [PMID: 28804679 DOI: 10.15404/msrj/03.2016.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neurological deterioration (ND) is common, with nearly one-half of ND patients deteriorating within the first 24 to 48 hours of stroke. The timing of ND with respect to ND etiology and reversibility has not been investigated. METHODS At our center, we define ND as an increase of 2 or more points in the National Institutes of Health Stroke Scale (NIHSS) score within 24 hours and categorize etiologies of ND according to clinical reversibility. ND etiologies were considered non-reversible if such causes may have produced or extended any areas of ischemic neurologic injury due to temporary or permanent impairment in cerebral perfusion. RESULTS Seventy-one of 350 ischemic stroke patients experienced ND. Over half (54.9%) of the patients who experienced ND did so within the 48 hours of last seen normal. The median time to ND for non-reversible causes was 1.5 days (IQR 0.9, 2.4 days) versus 2.6 days for reversible causes (IQR 1.4, 5.5 days, p=0.011). After adjusting for NIHSS and hematocrit on admission, the log-normal survival model demonstrated that for each 1-year increase in a patient's age, we expect a 3.9% shorter time to ND (p=0.0257). In addition, adjusting for age and hematocrit on admission, we found that that for each 1-point increase in the admission NIHSS, we expect a 3.1% shorter time to ND (p=0.0034). CONCLUSIONS We found that despite having similar stroke severity and age, patients with nonreversible causes of ND had significantly shorter median time to ND when compared to patients with reversible causes of ND.
Collapse
Affiliation(s)
- James E Siegler
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA 70112
| | - Karen C Albright
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 35294.,Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at Birmingham, 35294.,Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities (CERED) Minority Health & Health Disparities Research Center (MHRC), University of Alabama at Birmingham, 35294.,Department of Neurology, School of Medicine, University of Alabama at Birmingham, 35294
| | - Alexander J George
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA 70112
| | - Amelia K Boehme
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 35294
| | - Michael A Gillette
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA 70112
| | - Andre D Kumar
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA 70112
| | - Monica Aswani
- Department of Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35249
| | - Sheryl Martin-Schild
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA 70112
| |
Collapse
|
20
|
Siegler JE, Martin-Schild S. Daily National Institutes of Health Stroke Scale examinations at stroke centers: why not do them? Int J Stroke 2015; 10:140-2. [PMID: 25598024 DOI: 10.1111/ijs.12416] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The National Institutes of Health Stroke Scale was originally designed to stratify patients according to stroke severity for clinical trials, and now it is used to predict disposition and prognosticate functional outcome. Many researchers have also adopted it to trend patient progress over time and detect early neurologic deterioration. However, few investigators have reported its utility in monitoring the daily progress of patients hospitalized for stroke. In the present article, the authors discuss the advantages of daily National Institutes of Health Stroke Scale assessments and our clinical experience with this invaluable tool.
Collapse
Affiliation(s)
- James E Siegler
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | | |
Collapse
|
21
|
Seners P, Turc G, Oppenheim C, Baron JC. Incidence, causes and predictors of neurological deterioration occurring within 24 h following acute ischaemic stroke: a systematic review with pathophysiological implications. J Neurol Neurosurg Psychiatry 2015; 86:87-94. [PMID: 24970907 DOI: 10.1136/jnnp-2014-308327] [Citation(s) in RCA: 171] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Early neurological deterioration (END) following ischaemic stroke is a serious event with manageable causes in only a fraction of patients. The incidence, causes and predictors of END occurring within 24 h of acute ischaemic stroke (END24) have not been systematically reviewed. We systematically reviewed Medline and Embase from January 1990 to April 2013 for all studies on END24 following acute ischaemic stroke (<8 h from onset). We recorded the incidence and presumed causes of and factors associated with END24. Thirty-six studies were included. Depending on the definition used, the incidence of END24 markedly varied among studies. Using the most widely used change in National Institutes of Health Stroke Scale ≥4 definition, the pooled incidence was 13.8% following thrombolysis, ascribed to intracranial haemorrhage and malignant oedema each in ∼20% of these. As other mechanisms were rarely reported, in the majority no clear cause was identified. Few data on END24 occurring in non-thrombolysed patients were available. Across thrombolysed and non-thrombolysed samples, the strongest and most consistent admission predictors were hyperglycaemia, no prior aspirin use, prior transient ischaemic attacks, proximal arterial occlusion and presence of early CT changes, and the most consistent 24 h follow-up associated factors were no recanalisation/reocclusion, large infarcts and intracranial haemorrhage. Finally, END24 was strongly predictive of poor outcome. The above findings are discussed with emphasis on END without a clear mechanism. Data on incidence and predictors of the latter subtype is scarce, and future studies using systematic imaging protocols should address its underlying pathophysiology. This may in turn lead to rational preventative and therapeutic measures for this ominous event.
Collapse
Affiliation(s)
- Pierre Seners
- Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Université Paris Descartes, Hôpital Sainte-Anne, Paris, France
| | - Guillaume Turc
- Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Université Paris Descartes, Hôpital Sainte-Anne, Paris, France
| | - Catherine Oppenheim
- Sorbonne Paris Cité, INSERM UMR S894, Service de Neuroradiologie, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
| | - Jean-Claude Baron
- Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Université Paris Descartes, Hôpital Sainte-Anne, Paris, France
| |
Collapse
|
22
|
New Thrombotic Events in Ischemic Stroke Patients with Elevated Factor VIII. THROMBOSIS 2014; 2014:302861. [PMID: 25580292 PMCID: PMC4280494 DOI: 10.1155/2014/302861] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 11/22/2014] [Accepted: 11/22/2014] [Indexed: 11/22/2022]
Abstract
Background. Heightened levels of Factor VIII (FVIII) have been associated with both arterial and venous thrombosis. While elevated FVIII is common during acute ischemic stroke (AIS), whether elevated FVIII confers an increased risk for recurrent thrombotic events (RTEs) following AIS has not been previously explored. Methods. Consecutive AIS patients who presented to our center between July 2008 and September 2013 and had FVIII measured during admission were identified from our stroke registry. Baseline characteristics and the occurrence of RTE (recurrent or progressive ischemic stroke, DVT/PE, and MI) were compared in patients with and without elevated FVIII levels. Results. Of the 298 patients included, 203 (68.1%) had elevated FVIII levels. Patients with elevated FVIII had higher rates of any in-hospital RTE (18.7% versus 8.4%, P = 0.0218). This association remained after adjustment for baseline stroke severity and etiology (OR 1.01, 95% CI 1.00–1.01, P = 0.0013). Rates of major disability were also higher in patients who experienced a RTE (17.8% versus 3.2%, P < 0.0001). Conclusion. A significantly higher frequency of in-hospital RTEs occurred in AIS patients with elevated FVIII. The occurrence of such events was associated with higher morbidity. Further study is indicated to evaluate whether FVIII is a candidate biomarker for increased risk of RTEs following AIS.
Collapse
|
23
|
Seners P, Turc G, Tisserand M, Legrand L, Labeyrie MA, Calvet D, Meder JF, Mas JL, Oppenheim C, Baron JC. Unexplained Early Neurological Deterioration After Intravenous Thrombolysis. Stroke 2014; 45:2004-9. [DOI: 10.1161/strokeaha.114.005426] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Early neurological deterioration (END) after anterior circulation stroke is a serious clinical event strongly associated with poor outcome. Regarding specifically END occurring within 24 hours of intravenous recombinant tissue-type plasminogen activator, apart from definite causes such as symptomatic intracranial hemorrhage and malignant edema whose incidence, predictors, and clinical management are well established, little is known about END without clear mechanism (END
unexplained
).
Methods—
We analyzed 309 consecutive patients thrombolysed intravenously ≤4.5 hours from onset of anterior circulation stroke. END
unexplained
was defined as a ≥4-point deterioration on 24-hour National Institutes of Health Stroke Scale, without definite mechanism on concomitant imaging. END
unexplained
and no-END patients were compared for pretreatment clinical and imaging (including magnetic resonance diffusion and diffusion/perfusion mismatch volumes) data and 24-hour post-treatment clinical (including blood pressure and glycemic changes) and imaging (24-hour recanalization) data, using univariate logistic regression. Exploratory multivariate analysis was also performed after variable reduction, with bootstrap analysis for internal validation.
Results—
Among 33 END patients, 23 (7% of whole sample) had END
unexplained
. END
unexplained
was associated with poor 3-month outcome (
P
<0.01). In univariate analysis, admission predictors of END
unexplained
included no prior use of antiplatelets (
P
=0.02), lower National Institutes of Health Stroke Scale score (
P
<0.01), higher glycemia (
P
=0.03), larger mismatch volume (
P
=0.03), and proximal occlusion (
P
=0.01), with consistent results from the multivariate analysis. Among factors recorded during the first 24 hours, only no recanalization was associated with END
unexplained
in multivariate analysis (
P
=0.02).
Conclusions—
END
unexplained
affected 7% of patients and accounted for most cases of END. Several predictors and associated factors were identified, with important implications regarding underlying mechanisms and potential prevention of this ominous event.
Collapse
Affiliation(s)
- Pierre Seners
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| | - Guillaume Turc
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| | - Marie Tisserand
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| | - Laurence Legrand
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| | - Marc-Antoine Labeyrie
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| | - David Calvet
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-François Meder
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-Louis Mas
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| | - Catherine Oppenheim
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-Claude Baron
- From the INSERM UMR S894, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (P.S., G.T., M.T., L.L., M.-A.L., D.C., J.-F.M., J.-L.M., C.O., J.-C.B.); and Service de Neurologie (P.S., G.T., D.C., J.-L.M., J.-C.B.) and Service de Neuroradiologie (M.T., L.L., M.-A.L., J.-F.M., C.O.), Centre Hospitalier Sainte-Anne, Paris, France
| |
Collapse
|