Favorable functional recovery in overweight ischemic stroke survivors: findings from the China National Stroke Registry

Association between BMI-based metabolic phenotypes and prevalence of intracranial atherosclerotic stenosis: a cross-sectional study

BACKGROUND

Obesity and metabolic syndrome (MetS) have been acknowledged to commonly co-exist and lead to increased risks of stroke, whereas the association between various BMI-based metabolic phenotypes and development of intracranial atherosclerotic stenosis (ICAS) remained controversial.

METHODS

A total of 5355 participants were included from the Asymptomatic Polyvascular Abnormalities Community (APAC) study. Participants were categorized into six groups according to their body mass index (BMI) and MetS status. ICAS was assessed using transcranial Doppler (TCD) Ultrasonography. Logistic regression was employed to evaluate the association between BMI-based metabolic phenotypes and ICAS.

RESULTS

704 participants were diagnosed with ICAS. Compared to the metabolic healthy normal weight (MH-NW) group, the metabolic unhealthy normal weight (MUH-NW) group demonstrated a higher risk of ICAS (full-adjusted odds ratio [OR], 1.91; 95% confidence interval [CI], 1.42-2.57), while no significant association was observed in the metabolic unhealthy obesity (MUO) group (full-adjusted OR, 1.07; 95% CI, 0.70-1.65) and other metabolic healthy groups regardless of BMI. The results were consistent across gender, age, smoking, alcohol intake, and physical activity subgroups.

CONCLUSION

The present study suggested that MUH-NW individuals had a significant association with increased risk of ICAS compared with MH-NW individuals.

Prognostic model of in-hospital ischemic stroke mortality based on an electronic health record cohort in Indonesia

Stroke patients rarely have satisfactory survival, which worsens further if comorbidities develop in such patients. Limited data availability from Southeast Asian countries, especially Indonesia, has impeded the disentanglement of post-stroke mortality determinants. This study aimed to investigate predictors of in-hospital mortality in patients with ischemic stroke (IS). This retrospective observational study used IS medical records from the National Brain Centre Hospital, Jakarta, Indonesia. A theoretically driven Cox's regression and Fine-Gray models were established by controlling for age and sex to calculate the hazard ratio of each plausible risk factor for predicting in-hospital stroke mortality and addressing competing risks if they existed. This study finally included 3,278 patients with IS, 917 (28%) of whom had cardiovascular disease and 376 (11.5%) suffered renal disease. Bivariate exploratory analysis revealed lower blood levels of triglycerides, low density lipoprotein, and total cholesterol associated with in-hospital-stroke mortality. The average age of patients with post-stroke mortality was 64.06 ± 11.32 years, with a mean body mass index (BMI) of 23.77 kg/m2 and a median Glasgow Coma Scale (GCS) score of 12 and an IQR of 5. Cardiovascular disease was significantly associated with IS mortality risk. NIHSS score at admission (hazard ratio [HR] = 1.04; 95% confidence interval [CI]: 1.00-1.07), male sex (HR = 1.51[1.01-2.26] and uric acid level (HR = 1.02 [1.00-1.03]) predicted survivability. Comorbidities, such as cardiovascular disease (HR = 2.16 [1.37-3.40], pneumonia (HR = 2.43 [1.42-4.15] and sepsis (HR = 2.07 [1.09-3.94, had higher hazards for post-stroke mortality. Contrarily, the factors contributing to a lower hazard of mortality were BMI (HR = 0.94 [0.89-0.99]) and GCS (HReye = 0.66 [0.48-0.89]. In summary, our study reported that male sex, NIHSS, uric acid level, cardiovascular diseases, pneumonia, sepsis. BMI, and GCS on admission were strong determinants of in-hospital mortality in patients with IS.

Dual effects of serum urate on stroke risk and prognosis: insights from Mendelian randomization

Background

To investigate the causal associations of serum urate (SUA) with stroke risk and prognosis using Mendelian randomization (MR) and the potential mediating role of stroke risk factors in the causal pathways.

Methods

We used the random-effects inverse variance weighting (IVW) as our primary method. We initially performed two-sample univariable MR (UVMR) to identify the causal associations of SUA (n = 437,354) with any stroke (AS, FinnGen: n = 311,635; MEGASTROKE: n = 446,696), ischemic stroke (IS, FinnGen: n = 212,774; MEGASTROKE: n = 440,328), intracranial hemorrhage (ICH, FinnGen: n = 343,663; ISGC: n = 3,026), functional outcome after ischemic stroke at 90d (n = 4,363), and motor recovery within 24 months after stroke (n = 488), and then multivariable MR (MVMR) to estimate the direct causal effects of SUA on these outcomes, adjusting for potential confounders. Finally, we further conducted a two-step MR to investigate the potential mediating role of body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), and estimated glomerular filtration rate (eGFR) in the identified causal pathways.

Results

Genetically predicted elevated SUA levels were significantly associated with increased risk of AS (meta-analysis: OR = 1.09, 95% CI [1.04-1.13], p = 3.69e-05) and IS (meta-analysis: OR = 1.10, 95% CI [1.01-1.19], p = 0.021) and with improved poor functional outcome after ischemic stroke at 90d (OR = 0.81, 95% CI [0.72-0.90], p = 1.79e-04) and motor recovery within 24 months after stroke (OR = 1.42, 95% CI [1.23-1.64], p = 2.15e-06). In MVMR, SBP and DBP significantly attenuated the causal effects of SUA on AS, IS, and functional outcome after ischemic stroke at 90d and motor recovery within 24 months after stroke. Further mediation analyses showed that SBP mediated 52.4 and 34.5% of the effects of SUA on AS and IS, while DBP mediated 28.5 and 23.4% of the causal effects, respectively.

Conclusion

This study supports the dual role of genetically predicted SUA in increasing stroke risk, especially ischemic stroke risk, and in improving functional outcome and motor recovery. SBP and DBP are key mediators lying on the causal pathways of SUA with AS and IS.

Effect of body mass index on inpatient rehabilitation outcome after stroke in a Southeast Asian cohort: a prospective study

INTRODUCTION

We examined the association between admission body mass index (BMI) and discharge rehabilitation functional outcome using the functional independence measure (FIM) in a Southeast Asian cohort of stroke patients during inpatient rehabilitation.

METHODS

A prospective, observational cohort study of stroke patients admitted to a single inpatient rehabilitation unit was conducted. Using the World Health Organization Asian standards, BMI was classified as underweight (<18.5 kg/m 2 ), normal (18.5-22.9 kg/m 2 ) and overweight (≥23 kg/m 2 ). The primary outcome measure was discharge FIM, and secondary outcomes included FIM gain, FIM efficiency and FIM effectiveness.

RESULTS

Two hundred and forty-seven stroke subjects were enrolled. The mean age of the cohort was 59.48 (standard deviation [SD] 12.35) years; 64.4% ( n = 159) were male and 52.6% ( n = 130) had ischaemic stroke. The distributions of underweight, normal and overweight based on BMI on admission were 10.9% ( n = 27), 33.2% ( n = 82) and 55.9% ( n = 138), respectively, and the distributions upon discharge were 11.7% ( n = 29), 38.1% ( n = 94) and 50.2% (n = 124), respectively. Significant small decreases in BMI from admission to discharge were found (median [interquartile range] 23.58 [23.40-24.70] vs. 23.12 [22.99-24.21]; P < 0.001). Similarly, clinically significant FIM gains (mean ΔFIM 26.71; 95% confidence interval 24.73, 28.69, P < 0.001) were noted after a median length of stay of 36 days. No significant relationships were found between BMI and discharge FIM ( P = 0.600), FIM gain ( P = 0.254), FIM efficiency ( P = 0.412) or FIM effectiveness ( P = 0.796).

CONCLUSION

Findings from this study unequivocally support the benefits of acute inpatient stroke rehabilitation. Patients in the obese BMI range tended to normalise during rehabilitation. Body mass index, whether underweight, normal or overweight, did not correlate with discharge FIM.

Low body mass index patients have worse outcomes after mechanical thrombectomy

BACKGROUND

There is evidence that frailty is an independent predictor of worse outcomes after stroke. Similarly, although obesity is associated with a higher risk for stroke, there are multiple reports describing improved mortality and functional outcomes in higher body mass index (BMI) patients in a phenomenon known as the obesity paradox. We investigated the effect of low BMI on outcomes after mechanical thrombectomy (MT).

METHODS

We conducted a retrospective analysis of 231 stroke patients who underwent MT at an academic medical center between 2020-2022. The patients' BMI data were collected from admission records and coded based on the Centers for Disease Control and Prevention (CDC) obesity guidelines. Recursive partitioning analysis (RPA) in R software was employed to automatically detect a BMI threshold associated with a significant survival benefit. Frailty was quantified using the Modified Frailty Index 5 and 11.

RESULTS

In our dataset, by CDC classification, 2.6% of patients were underweight, 27.3% were normal BMI, 30.7% were overweight, 19.9% were class I obese, 9.5% were class II obese, and 10% were class III obese. There were no significant differences between these groups. RPA identified a clinically significant BMI threshold of 23.62 kg/m2. Independent of frailty, patients with a BMI ≤23.62 kg/m2 had significantly worse overall survival (P<0.001) and 90-day modified Rankin Scale (P=0.027) than patients above the threshold.

CONCLUSIONS

Underweight patients had worse survival and functional outcomes after MT. Further research should focus on the pathophysiology underlying poor prognosis in underweight MT patients, and whether optimizing nutritional status confers any neuroprotective benefit.

Role of age and sex in the association between BMI and functional limitations in stroke patients: Cross-sectional analysis in three European and US cohorts

BACKGROUND

A U- or J-shaped association between BMI and different post-stroke outcomes is suggested. Thus, the aim is to evaluate the association between BMI with ADL, IADL and mobility limitations in the ageing post-stroke population at different ages, as well as the differences in this association by sex.

METHODS

A total of 5,468 participants with stroke and 21,872 without stroke over 50 years of age were assessed for the number of limitations in basic or instrumental activities of daily living (ADL/IADL) as well as mobility tasks. The association between BMI at the interview (continuous time-dependent variable) and the level of limitations was assessed using a linear mixed model stratified by sex and stroke status.

RESULTS

The association between BMI and ADL/IADL and mobility limitations were found to be significant in both men and women regardless of stroke status (p<0.001 for all). The association differs between those who have suffered a stroke and those who have not (p<0.001 for all). In ADL/IADL limitations, men with stroke showed a transition from an inverted J-shape to a U-shape association with age. In women, the BMI showed a less pronounced association between BMI and ADL/IADL limitations compared to men but with similar trends. A effect of sex was observed in the association between BMI and mobility, with women with and without stroke showing a linear association that differed from the inverted J-shaped or U-shaped association of men.

CONCLUSION

Our results suggest that BMI is associated with limitations in ADL, IADL and mobility in stroke patients. In addition, this association differs between men and women and is also influenced by age.

Effects of body mass index on the immune response within the first days after major stroke in humans

INTRODUCTION

Immunological alterations associated with increased susceptibility to infection are an essential aspect of stroke pathophysiology. Several immunological functions of adipose tissue are altered by obesity and are accompanied by chronic immune activation. The purpose of this study was to examine immune function (monocytes, granulocytes, cytokines) as a function of body mass index (BMI: 1st group: 25; 2nd group: 25 BMI 30; 3rd group: 30) and changes in body weight post stroke.

METHOD

Fat status was assessed using standardized weight measurements on days 1, 2, 3, 4, 5, and 7 after ischemic stroke in a cohort of 40 stroke patients and 16 control patients. Liver fat and visceral fat were assessed by MRI on day 1 or 2 [I] and on day 5 or 7 [II]. Leukocyte subpopulations in peripheral blood, cytokines, chemokines, and adipokine concentrations in sera were quantified. In a second cohort (stroke and control group, n = 17), multiple regression analysis was used to identify correlations between BMI and monocyte and granulocyte subpopulations.

RESULTS

Weight and fat loss occurred from the day of admission to day 1 after stroke without further reduction in the postischemic course. No significant changes in liver or visceral fat were observed between MRI I and MRI II. BMI was inversely associated with IL-6 levels, while proinflammatory cytokines such as eotaxin, IFN-β, IFN -γ and TNF-α were upregulated when BMI increased. The numbers of anti-inflammatory CD14+CD16+ monocytes and CD16+CD62L- granulocytes were reduced in patients with higher BMI values, while that of proinflammatory CD16dimCD62L+ granulocytes was increased.

CONCLUSION

A small weight loss in stroke patients was detectable. The data demonstrate a positive correlation between BMI and a proinflammatory poststroke immune response. This provides a potential link to how obesity may affect the clinical outcome of stroke patients.

Non-linear association between body weight and functional outcome after acute ischemic stroke

This study aimed to determine whether body weight is associated with functional outcome after acute ischemic stroke. We measured the body mass index (BMI) and assessed clinical outcomes in patients with acute ischemic stroke. The BMI was categorized into underweight (< 18.5 kg/m²), normal weight (18.5-22.9 kg/m²), overweight (23.0-24.9 kg/m²), and obesity (≥ 25.0 kg/m²). The association between BMI and a poor functional outcome (modified Rankin Scale [mRS] score: 3-6) was evaluated. We included 11,749 patients with acute ischemic stroke (70.3 ± 12.2 years, 36.1% women). The risk of a 3-month poor functional outcome was higher for underweight, lower for overweight, and did not change for obesity in reference to a normal weight even after adjusting for covariates by logistic regression analysis. Restricted cubic splines and SHapley Additive exPlanation values in eXtreme Gradient Boosting model also showed non-linear relationships. Associations between BMI and a poor functional outcome were maintained even after excluding death (mRS score: 3-5) or including mild disability (mRS score: 2-6) as the outcome. The associations were strong in older patients, non-diabetic patients, and patients with mild stroke. Body weight has a non-linear relationship with the risk of a poor functional outcome after acute ischemic stroke.

Obesity paradox and stroke outcomes according to stroke subtype: a propensity score-matched analysis

OBJECTIVE

Obesity has traditionally been considered a risk factor for ischemic stroke. However, some clinical observations have reported a complex relationship between patients who are overweight or obese with paradoxically better stroke outcomes. Stroke subtypes have differing distributions of risk factors, so this study aimed to explain the relationship between body mass index (BMI) and functional prognosis according to stroke subtype.

METHODS

A prospective institutional database on stroke was accessed between March 2014 and December 2021, and consecutive patients with ischemic stroke were retrospectively selected. BMI was categorized into five groups (underweight, normal weight, overweight, obese, and morbid obesity). The outcome of interest in this study was the modified Rankin Scale (mRS) at 90 d, which was divided into favorable (mRS = 0-2) and unfavorable (mRS ≥ 3) groups. The relationship between functional outcome and BMI was analyzed according to stroke subtype.

RESULTS

Among 2779 patients with stroke, 913 (32.9%) had unfavorable outcomes. After a propensity score-matched analysis, obesity was inversely associated with unfavorable outcomes (adjusted odds ratio [aOR] = 0.61, 95% confidence interval [95% CI]: 0.46-0.80) in all patients with stroke. Among the stroke subtypes, overweight (aOR = 0.38, 95% CI: 0.20-0.74) and obese (aOR = 0.40, 95% CI: 0.21-0.76) groups were inversely associated with unfavorable outcomes in the cardioembolism subtype. Obesity (aOR = 0.55, 95% CI: 0.32-0.95) was inversely associated with unfavorable outcomes in the small vessel disease subtype. There was no significant relationship between stroke outcome and BMI classification in the large artery disease subtype.

CONCLUSIONS

These findings suggest that the obesity paradox in ischemic stroke outcomes might differ according to the stroke subtype.

A Cross-Sectional Study: Determining Factors of Functional Independence and Quality of Life of Patients One Month after Having Suffered a Stroke

(1) Background: loss of quality of life (QoL) and functional independence are two of the most common consequences of suffering a stroke. The main objective of this research is to study which factors are the greatest determinants of functional capacity and QoL a month after suffering a stroke so that they can be considered in early interventions. (2) Methods: a cross-sectional study was conducted which sample consisted of 81 people who had previously suffered a stroke. The study population was recruited at the time of discharge from the Neurology Service and Stroke Unit of the hospitals of Burgos and Córdoba, Spain, through a consecutive sampling. Data were collected one month after participants experienced a stroke, and the main study variables were quality of life, measured with the Stroke-Specific Quality of Life Measure (NEWSQOL), and functional independence, measured with the Functional Independence Measure-Functional Assessment Measure (FIM-FAM). (3) Results: the factors associated with a worse QoL and functional capacity one month after having suffered a stroke were living in a different dwelling than the usual flat or house (p < 0.05), a worse cognitive capacity (p < 0.001) and a worse functional capacity of the affected upper limb (p < 0.001). A higher age was related to a worse functional capacity one month after suffering a stroke (p = 0.048). (4) Conclusions: the type of dwelling, age, cognitive ability and functional capacity of the affected upper limb are determining aspects in functional independence and QoL during the first weeks after a stroke.

The relationship between nutritional status at the time of stroke on adverse outcomes: a systematic review and meta-analysis of prospective cohort studies

CONTEXT AND OBJECTIVE

The impact of existing malnutrition on stroke outcomes is poorly recognised and treated. Evidence was systematically reviewed and quantified by meta-analysis.

METHODS

MEDLINE, EMBASE and Web of Science were searched from inception to 11 January 2021 and updated in July. Prospective cohort studies, in English, evaluating anthropometric and biomarkers of nutrition on stroke outcomes were included. Risk of bias was assessed using the Scottish Intercollegiate Guidelines Network checklist.

RESULTS

Twenty-six studies (n = 156 249) were eligible (follow-up: One month-14 years). Underweight patients had increased risk of long-term mortality (adjusted hazard ratio = 1.65,1.41-1.95), whilst overweight (0.80,0.74-0.86) and obese patients (0.80,0.75-0.85) had decreased risk compared to normal weight. Odds of mortality decreased in those with high serum albumin (odds ratio = 0.29,0.18-0.48) and increased with low serum albumin (odds ratio = 3.46,1.78-6.74) compared to normal serum albumin (30-35 g/L). Being malnourished compared to well-nourished, as assessed by the Subjective Global Assessment (SGA) or by a combination of anthropometric and biochemical markers increased all-cause mortality (odds ratio = 2.38,1.85-3.06) and poor functional status (adjusted odds ratio = 2.21,1.40-3.49).

CONCLUSION

Nutritional status at the time of stroke predicts adverse stroke outcomes.

Predictors beyond the lesion: Health and demographic factors associated with aphasia severity

BACKGROUND

Lesion-related factors are associated with severity of language impairment in persons with aphasia. The extent to which demographic and health factors predict language impairment beyond traditional cortical measures remains unknown. Identifying and understanding the contributions of factors to predictive models of severity constitutes critical knowledge for clinicians interested in charting the likely course of aphasia in their patients and designing effective treatment approaches in light of those predictions.

METHODS

Utilizing neuroimaging and language testing from our cohort of 224 individuals in the chronic stage of recovery from a left-hemisphere stroke in a cross-sectional study, we first conducted a lesion symptom mapping (LSM) analysis to identify regions associated with aphasia severity scores. After controlling for lesion volume and damage to pre-identified areas, three models were created to predict severity scores: 1) Demographic Model (N = 147); 2) Health Model (N = 106); and 3) Overall Model (N = 106). Finally, all identified factors were entered into a Final Model to predict raw severity scores.

RESULTS

Two areas were associated with aphasia severity-left posterior insula and left arcuate fasciculus. The results from the Demographic Model revealed non-linguistic cognitive ability, age at stroke, and time post-stroke as significant predictors of severity (P = .005; P = .02; P = .001, respectively), and results from the Health Model suggested the extent of leukoaraiosis is associated with severity (P = .0004). The Overall Model showed a relationship between aphasia severity and cognitive ability (P = .01), time post-stroke (P = .002), and leukoaraiosis (P = .01). In the Final Model, which aimed to predict raw severity scores, demographic, health, and lesion factors explained 55% of the variance in severity, with health and demographic factors uniquely explaining nearly half of performance variance.

CONCLUSIONS

Results from this study add to the literature suggesting patient-specific variables can shed light on individual differences in severity beyond lesion factors. Additionally, our results emphasize the importance of non-linguistic cognitive ability and brain health in aphasia recovery.

Mortality Rate of Ischemic Stroke Patients Undergoing Decompressive Hemicraniectomy With Obesity

Background Obesity has been shown to have a positive mortality benefit in patients undergoing percutaneous coronary intervention and dialysis and those with rheumatoid arthritis, chronic obstructive pulmonary disease, and various wasting diseases. Studies for this mortality benefit in ischemic stroke patients are conflicting and have not been well studied in hemicraniectomy patients. We sought to determine the impact of obesity on outcomes of hemicraniectomy patients. Methods We performed a retrospective case-control database analysis using a multi-institutional database (TriNetX) looking at obese versus non-obese patients with ischemic stroke undergoing hemicraniectomy. Our primary endpoint was mortality. Secondary endpoints included seizure, pulmonary embolism, myocardial infarction (MI), cerebral infarction, deep vein thrombosis, tracheostomy, and percutaneous endoscopic gastrostomy. Cohorts were propensity-score matched for confounders. Results After propensity score matching for basic demographics and common comorbidities, as well as indicators of stroke severity, 646 patients were identified that were obese and had an ischemic stroke with subsequent hemicraniectomy (cohort 1), and 646 patients were identified who were non-obese with ischemic stroke and hemicraniectomy (cohort 2). Thirty-day survival rate was 98.142% in the obese vs. 87.771% in the non-obese cohorts, 90-day survival was 85.15% vs. 79.35%, 180-day survival was 96.44% vs. 84.52%, 365-day survival was 94.272% vs. 81.734%, and five-year survival was 81.889% vs. 75.077%, respectively. At five years, risk difference was -7.276% (95% CI: -11.757, -2.794) and odds ratio was 0.666 (95% CI: 0.510, 0.871) (p = 0.0029). Despite a higher mortality rate, obese patients had a statistically significant increase in pulmonary embolism (11.61% vs. 5.108, p < 0.0001), deep venous thrombosis (16.873% vs. 9.133%, p < 0.0001), and MI (8.824% vs. 5.882%, p = 0.0428). There was no significant difference in intensive care unit length of stay, ventilator dependence, tracheostomy placement, percutaneous endoscopic gastrostomy placement, or intracerebral hemorrhage. Conclusions Despite the increased risk of ischemic stroke, obese patients who undergo hemicraniectomy have decreased mortality rates compared to their non-obese counterparts.

Higher BMI Confers a Long-Term Functional Status Advantage in Elderly New Zealand European Stroke Patients

OBJECTIVE

Obesity is a risk factor for ischaemic stroke but provides a survival advantage. The relationship between body mass index (BMI) and long-term function is less clear. The presence of an obesity paradox can inform clinical care and identify vulnerable patients who need additional support post-stroke.

MATERIALS AND METHODS

This study used linked health administrative data of a population based cohort of adult patients who experienced an ischaemic stroke between 2012 and 2017 in New Zealand. Patient demographics were obtained from the National Minimum Dataset (NMDS). BMI and Activities of Daily Living scores (ADLs) for the same patients were obtained from the International Resident Assessment Instrument (InterRAI™).

RESULTS

Linked data was obtained for 3731 patients. Ninety-five percent of the cohort were aged 65 or older and the average age of stroke was 84.5 years. The majority of patients (55%) identified as New Zealand European. Beta regression indicated BMI and European ethnicity were negatively associated with ADL score. Univariate analysis confirmed patients with underweight stroke had significantly higher ADL scores than other BMI categories (p<0.001), however functional status for patients with overweight and obesity were comparable. Further, Asian and Pacific Peoples had higher ADL scores than Europeans (p<0.05). A higher BMI was advantageous to all ADL subscores.

CONCLUSION

An abridged obesity paradox was evident in our cohort of stroke patients where a BMI in the overweight, but not obese range conferred a long-term functional status advantage. Collectively these results suggest underweight and non-European patients may require additional supportive clinical care post-stroke.

Obesity and Stroke: Does the Paradox Apply for Stroke?

Historically, obesity has been identified as one of the most important risk factors for developing cardiovascular diseases including stroke; however, a theory called "The Obesity Paradox" has been recently considered. The paradoxical theory is that obese or overweight patients (according to body mass index score) can have better outcomes compared to leaner or malnourished patients. The paradox was initially discovered in patients with heart failure. The purpose of this manuscript was to investigate whether this paradox also applies to stroke patients, according to information available in the current literature.

Obesity paradox and stroke: a narrative review

BACKGROUND

Despite obesity is an established risk factor for stroke, several studies reported a better outcome after stroke in obese and overweight patients. This counterintuitive finding, which was described in the whole spectrum of cardiovascular diseases, is known as obesity paradox.

OBJECTIVE

This is a narrative overview on the obesity paradox and stroke.

METHODS

We used as sources MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library from inception to 2019, and selected papers that discussed the association of obesity with outcome and mortality after stroke.

RESULTS

The majority of studies reported lower mortality rates and better functional outcome after stroke in obese and overweight patients compared with normal weight and underweight patients, suggesting the existence of an obesity paradox in stroke. However, available studies are limited by several major methodological concerns including absence of randomized trials, retrospective nature of most studies, assessment of obesity with body mass index (BMI), non-linear relationship between BMI and outcome, short follow-up period, and differences in co-morbid conditions and stroke characteristics.

CONCLUSIONS

The existence of an obesity paradox in stroke is still controversial and further higher quality evidence is needed to clarify the relationship between obesity and stroke outcome.

LEVEL OF EVIDENCE

Level V, narrative review.

Body mass index and clinical outcomes in patients with intracerebral haemorrhage: results from the China Stroke Center Alliance

Background and aim

Obesity paradox has aroused increasing concern in recent years. However, impact of obesity on outcomes in intracerebral haemorrhage (ICH) remains unclear. This study aimed to evaluate association of body mass index (BMI) with in-hospital mortality, complications and discharge disposition in ICH.

Methods

Data were from 85 705 ICH enrolled in the China Stroke Center Alliance study. Patients were divided into four groups: underweight, normal weight, overweight and obese according to Asian-Pacific criteria. The primary outcome was in-hospital mortality. The secondary outcomes included non-routine discharge disposition and in-hospital complications. Discharge to graded II or III hospital, community hospital or rehabilitation facilities was considered non-routine disposition. Multivariable logistic regression analysed association of BMI with outcomes.

Results

82 789 patients with ICH were included in the final analysis. Underweight (OR=2.057, 95% CI 1.193 to 3.550) patients had higher odds of in-hospital mortality than those with normal weight after adjusting for covariates, but no significant difference was observed for patients who were overweight or obese. No significant association was found between BMI and non-disposition. Underweight was associated with increased odds of several complications, including pneumonia (OR 1.343, 95% CI 1.138 to 1.584), poor swallow function (OR 1.351, 95% CI 1.122 to 1.628) and urinary tract infection (OR 1.532, 95% CI 1.064 to 2.204). Moreover, obese patients had higher odds of haematoma expansion (OR 1.326, 95% CI 1.168 to 1.504), deep vein thrombosis (OR 1.506, 95% CI 1.165 to 1.947) and gastrointestinal bleeding (OR 1.257, 95% CI 1.027 to 1.539).

Conclusions

In patients with ICH, being underweight was associated with increased in-hospital mortality. Being underweight and obese can both increased risk of in-hospital complications compared with having normal weight.

Obesity and Mechanical Thrombectomy

Background Obesity has been shown to have a positive mortality benefit in patients undergoing percutaneous coronary intervention, dialysis, those with rheumatoid arthritis, chronic obstructive pulmonary disease, and various wasting diseases. Studies for this mortality benefit in ischemic stroke patients are conflicting, and it has not been well studied in mechanical thrombectomy patients. We sought to determine the impact of obesity on outcomes of mechanical thrombectomy patients. Methodology We used a large global health research network to gather clinical data extracted from the electronic medical records of ischemic stroke patients who underwent mechanical thrombectomy, and then stratified these patients into obese and non-obese cohorts. The primary endpoint was mortality. Results After propensity score matching, obese patients who underwent mechanical thrombectomy had decreased mortality (p = 0.0033, odds ratio = 0.81, 95% confidence interval = 0.704,0.932) compared to non-obese patients. No statistically significant difference was shown between these two cohorts for the outcomes of ventilator dependence, hemicraniectomy, or post-procedure intracerebral hemorrhage. Conclusion Despite increasing risk of ischemic stroke, obese patients who undergo mechanical thrombectomy have decreased mortality rates compared to their non-obese counterparts.

Adiposity and Outcome After Ischemic Stroke: Obesity Paradox for Mortality and Obesity Parabola for Favorable Functional Outcomes

BACKGROUND AND PURPOSE

A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality.

METHODS

We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2-6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables.

RESULTS

Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival (P=0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6-4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5-1.4]), obese (0.5, [CI, 0.3-1.0]), and severely obese (0.4 [CI, 0.2-0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2-6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity.

CONCLUSIONS

Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients' adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

Association between dynamic obesity and mortality in patients with first-ever ischemic stroke: A hospital-based prospective study

Although obesity is an established risk factor of primary stroke, the association between obesity and post-stroke mortality remains unclear. The aim of this study was to investigate the association between dynamic obesity status and mortality in survivors of their first stroke in China.Of 775 patients with first-ever ischemic stroke included in a longitudinal study, 754 patients were included in this study and categorized into 4 categories of body mass index (BMI) (underweight, normal weight, overweight, and obese) and 2 categories of waist circumference (WC) (normal WC and abdominal obesity) according to standard Chinese criteria. The mortality information and obesity status were obtained via telephone follow-up every 3 months, beginning in 2010 through 2016. Time-dependent Cox proportional hazards models were used to estimate the unadjusted and adjusted hazard ratios (HRs) for the relationship between all-cause mortality and dynamic obesity status.Of 754 patients, 60.87% were male, and the overall mean age was 61.45 years. After adjusting for possible confounders, significant inverse associations were identified between BMI and WC and all-cause mortality. Compared with those with normal BMI or WC, those with abdominal obesity or overweight had a significantly lower risk of all-cause mortality (HR and 95% confidence intervals [CIs]: .521 [.303-.897] and 0.545 [.352-.845], respectively), whereas patients with underweight had the highest risk and those with obesity had lower risk of mortality, though it was not statistically significant (1.241 [.691-2.226] and .486 [.192-1.231], respectively).Overweight and abdominal obesity were paradoxically associated with reduced risk of mortality in patients who survived their first-ever ischemic stroke in China. Future prospective studies must look at evaluating the role of obesity in different stroke subtypes and devise appropriate weight-management strategies for optimal prognoses in secondary prevention in these survivors.

Prognostic Nutritional Index for Predicting 3-Month Outcomes in Ischemic Stroke Patients Undergoing Thrombolysis

Objective: Malnutrition has been reported to be related to adverse prognosis in acute ischemic stroke (AIS) patients. Unfortunately, traditional nutritional assessment tools usually increase the workload of neurologists, which makes them unfeasible in the daily clinic work. We aimed to elucidate the association between the prognostic nutritional index (PNI), an easily obtainable baseline nutritional marker, and 3-month outcomes in AIS patients receiving intravenous thrombolysis (IVT).

Research methods and procedures: The present study retrospectively included 405 patients. PNI was calculated as 5^*lymphocyte count (10⁹ /L) + serum albumin concentration (g/L), and the good prognosis was defined as modified Rankin Scale score of 0–3. The relationship between PNI and clinical parameters was evaluated. The multiple logistic regression model was performed to find out independent predictors of the 3-month outcomes.

Results: We found that the patients in the low PNI group had a higher frequency of anemia (12.9 vs. 2.3%, P < 0.001) and a higher level of the Controlling nutritional status (CONUT) score (P < 0.001). The relationship between PNI and nutrition-related factors, such as body mass index (r = 0.208, P = 0.001), age (r = −0.329, P < 0.001), total cholesterol (r = 0.268, P < 0.001) and hemoglobin concentration (r = 0.328, P < 0.001), was significant. Low PNI value (adjusted odds ratio: 2.250, confidence interval: 1.192–4.249, p = 0.012) stayed as an independent predictor for the poor outcome at three months, after adjustment for potential confounders.

Conclusions: The PNI was independently associated with 3-month outcomes in AIS patients undergoing IVT. As an easily obtainable nutritional marker, PNI may be a useful nutritional assessment tool in the clinic work.

Sex influence in ischemic stroke severity and outcome among metabolically unhealthy overweight patients

INTRODUCTION

The role of metabolically unhealthy (MU) overweight in influencing stroke prognosis has not been fully assessed and conclusive data about the impact of sex are lacking. Aim of this study was to evaluate the possible correlations among MU overweight, sex and ischemic stroke severity and outcome.

METHODS

All consecutive patients with acute non-lacunar ischemic stroke observed over a one-year period were considered. MU subjects were selected and classified according to the body mass index (BMI) values. The relationships among sex, BMI and National Institutes of Health Stroke Scale (NIHSS) score at admission and modified Rankin scale (mRS) score at discharge were analysed with multivariate models.

RESULTS

180 patients were included. A significantly increasing trend in the NIHSS (p = .030) and in the mRS (p = .001) scores along with the increase of the BMI category was detected in women. Men showed a significantly decreasing trend in the NIHSS (p = .040) and a non-significant decreasing trend in the mRS (p = .290) scores with increasing BMI category.

CONCLUSIONS

Our findings show that sex can influence stroke severity and outcome among MU patients. The worse outcome observed in women suggest the need of considering differential sex-based clinical approaches in stroke overweight patients.

Dietary habits, lifestyle factors and neurodegenerative diseases

Worldwide stroke is increasing in parallel with modernization, changes in lifestyle, and the growing elderly population. Our review is focused on the link between diet, as part of 'modern lifestyle', and health in the context of genetic predisposition of individuals to 'unhealthy' metabolic pathway activity. It is concluded that lifestyle including high sugar diets, alcohol and tobacco addiction or high fat diets as well as ageing, brain injury, oxidative stress and neuroinflammation, negatively influence the onset, severity and duration of neurodegenerative diseases. Fortunately, there are several healthy dietary components such as polyunsaturated fatty acids and the anti-oxidants curcumin, resveratrol, blueberry polyphenols, sulphoraphane, salvionic acid as well as caloric restriction and physical activity, which may counteract ageing and associated neurodegenerative diseases via increased autophagy or increased neurogenesis in the adult brain.

Changes in Language Function and Recovery-Related Prognostic Factors in First-Ever Left Hemispheric Ischemic Stroke

Objective

To investigate longitudinal changes in language function in left-hemispheric ischemic stroke patients as well as factors that influence language recovery until 1 year after stroke onset.

Methods

We analyzed data from 235 patients with first-ever left-hemispheric ischemic stroke. All patients completed the Korean version of the Frenchay Aphasia Screening Test (K-FAST) at 7 days (T1), 3 months (T2), 6 months (T3), and 1 year (T4) after stroke onset. Repeated measures analysis of variance (ANOVA) was used to investigate changes in language function between time points. Subgroup analysis was performed according to the K-FAST scores at T1. Stroke lesion volume was assessed using diffusion tensor images, and involvement of language-related brain regions was examined. Multiple regression analysis was used to analyze factors influencing improvement of K-FAST score.

Results

The K-FAST scores at T1, T2, T3, and T4 differed significantly (p<0.05). In the subgroup analysis, only the severe group showed continuous significant improvement by 1 year. Factors that negatively influenced improvement of language function were the age at onset, initial National Institutes of Health Stroke Scale (NIHSS) score, and initial K-FAST score, whereas education level and stroke lesion volume positively affected recovery. Involvement of language-related brain regions did not significantly influence long-term language recovery after ischemic stroke.

Conclusion

Recovery of language function varied according to the severity of the initial language deficit. The age at stroke onset, education level, initial severity of aphasia, initial NIHSS score, and total stroke lesion volume were found to be important factors for recovery of language function.

Body mass index and recovery of activities of daily living in older patients with femoral fracture: An analysis of a national inpatient database in Japan

OBJECTIVE

To evaluate the effects of body mass index (BMI) on recovery of activities of daily living (ADL) in older Asian patients with femoral fracture registered in a nationwide inpatient database in Japan.

METHODS

We retrospectively analyzed data of patients aged ≥65 years with acute femoral fracture between April 2014 and November 2017 in the Diagnosis Procedure Combination database. Patients were classified into the following categories based on BMI (kg/m²): underweight (<18.5); normal weight (18.5-22.9); overweight (23-27.4); obese (≥27.5); and missing data. Demographic data included age, sex, type of fracture, comorbidities, and Barthel Index (BI). The primary outcome was BI at discharge and secondary outcomes were the overall complication rate and discharge to home.

RESULTS

In total, data for 13,348 patients were extracted from the database, of whom 80.3 % were female. At discharge, underweight patients had lower BI than overweight or obese patients. In multivariable analysis, underweight and missing BMI data were associated with lower BI at discharge (partial regression coefficients -2.324 and -5.763, respectively). In contrast, overweight and obese were correlated with higher BI (3.080 and 5.732, respectively). Underweight was independently associated with a higher overall complication rate (odds ratio 1.195) and a lower rate of discharge to home (odds ratio 0.865).

CONCLUSIONS

Underweight was associated with poorer performance in ADL, higher risk of complications, and lower rate of discharge to home in older Asian patients with femoral fracture. Overweight and obese had positive effects on ADL.

Factors Associated with Inpatient Mortality after Intracerebral Hemorrhage: Updated Information from the United States Nationwide Inpatient Sample

BACKGROUND

To use a nationwide database of hospital admissions to assess for trends in inpatient mortality from acute spontaneous intracerebral hemorrhage as well as associated potentially contributing factors.

METHODS

Adults with intracerebral hemorrhage in the US National Inpatient Sample database from 2012 to 2015 were included in this study. We assessed for mortality rate as well as potential impact of various comorbidities and demographic factors such as ethnicity and median house hold income on inpatient mortality rate.

RESULTS

A total of 47,700 patients were identified with a mean age of 68 years. The overall mortality rate was 24%. Hypertension was the commonest comorbidity (84%) followed by diabetes mellitus (28%). Positive associated factors for mortality rate were coagulopathy (OR 1.28, 95% CI 1.19-1.38, P < .001), female gender (OR 1.12, 95% CI 1.08-1.17, P < .001), and congestive heart failure (OR 1.16, 95% CI 1.08-1.24, P < .001). Age greater than 75 was also associated with higher mortality (P < .001). Factors associated with reduced mortality were hypertension (OR .76, 95% CI .72-0.81, P < .001), hypothyroidism (OR .87, 95% CI .81-.93, P < .001) and obesity (OR .64, 95% CI .59-.69, P < .001).

CONCLUSIONS

The inpatient mortality of 24% represents a decline when compared to previous years. Attention to the associated factors with mortality, that we report, could have some potential impact on management. Of interest, we found support for obesity paradox in which obesity may have an actual salutary effect on vascular disease outcome. Our observed paradoxical effects, not only for obesity, but also hypertension and hypothyroidism, warrant further study.

The Effect of Body Mass Index on Outcome after Endovascular Treatment in Acute Ischemic Stroke Patients: A Post Hoc Analysis of the MR CLEAN Trial

BACKGROUND

Though obesity is a well-known risk factor for vascular disease, the impact of obesity on stroke outcome has been disputed. Several studies have shown that obesity is associated with better functional outcome after stroke. Whether obesity influences the benefit of endovascular treatment (EVT) in stroke patients is unknown. We evaluated the association between body mass index (BMI) and outcome in acute ischemic stroke patients with large vessel -occlusion (LVO), and assessed whether BMI affects the -benefit of EVT.

METHODS

This is a post hoc analysis of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands trial (-ISRCTN10888758). BMI was used as a continuous and categorical variable, distinguishing underweight and normal weight (BMI <25), overweight (BMI 25-30), and obesity (BMI ≥30). We used multivariable ordinal logistic regression analysis to estimate the association of BMI with functional outcome (shift analysis), assessed with modified Rankin Scale (mRs) at 90 days. The impact of BMI on EVT effect was tested by the use of a multiplicative interaction term.

RESULTS

Of 366 patients, 160 (44%) were underweight or normal weight, 145 (40%) overweight, and 61 (17%) were obese. In multivariable analysis with BMI as a continuous variable, we found a shift toward better functional outcome with higher BMI (mRS adjusted common OR 1.04; 95% CI 1.0-1.09), and mortality was inversely related to BMI (aOR 0.92; 95% CI 0.85-0.99). Safety analysis showed that higher BMI was associated with lower risk of stroke progression (aOR 0.92, 95% CI 0.87-0.99). Additional analysis showed no interaction between BMI and EVT effect on functional outcome, mortality, and other safety outcomes.

CONCLUSION

Our study confirms the effect of obesity on outcome in acute ischemic stroke patients with LVO, meaning better functional outcome, lower mortality, and lower risk of stroke progression for patients with higher BMI. As we found no interaction between BMI and EVT effect, all BMI classes may expect the same benefit from EVT.

Uric Acid Contributes to Obesity-Paradox of the Outcome of Ischemic Stroke

Background: The mechanism of obesity paradox in stroke is not clear. This study aimed to investigate whether uric acid (UA) contributes to obesity-stroke outcome paradox.

Material and Methods: The study cohort consisted of 1,984 IS patients recruited in the ACROSS-China study. Serum UA and BMI were measured at admission. Low and high BMI groups were defined by the threshold of 24, and low and high UA by the age- and sex-specific median. Poor outcomes were defined as modified Rankin scale score ≥3 in 1 year after onset.

Results: UA was significantly and positively correlated with BMI. Lower levels of UA and BMI were significantly associated with higher risk of poor outcomes. Incidence of the poor outcome was 34.5, 29.4, 27.7, and 23.5% in the BMI/UA groups of low/low, high/low, low/high and high/high, respectively, with p = 0.001 for trend. The association between low UA and poor outcome was significant in lower BMI groups (odds ratio = 1.36, p = 0.006 in quartile 1 and 1.28, p = 0.021 in quartile 2), but the odds ratios were not significant in the BMI quartile 3 and 4 groups, with p = 0.038 for trend. The adverse effect of lower UA was significant in males, but not in females, with p = 0.006 for sex difference.

Conclusions: These findings suggest that low UA and low BMI have a joint effect on poor outcomes in IS patients. Across BMI categories, uric acid is differentially associated with functional outcome after stroke. This effect of low UA in the low BMI groups may be one of the mechanisms underlying the obesity-stroke paradox of the outcome in IS patients.

Obesity paradox in subarachnoid hemorrhage: a systematic review

As the number of obese people is globally increasing, reports about the putative protective effect of obesity in life-threatening diseases, such as subarachnoid hemorrhage (SAH), are gaining more interest. This theory-the obesity paradox-is challenging to study, and the impact of obesity has remained unclear in survival of several critical illnesses, including SAH. Thus, we performed a systematic review to clarify the relation of obesity and SAH mortality. Our study protocol included systematic literature search in PubMed, Scopus, and Cochrane library databases, whereas risk-of-bias estimation and quality of each selected study were evaluated by the Critical Appraisal Skills Program and Cochrane Collaboration guidelines. A directional power analysis was performed to estimate sufficient sample size for significant results. From 176 reviewed studies, six fulfilled our eligibility criteria for qualitative analysis. One study found paradoxical effect (odds ratio, OR = 0.83 (0.74-0.92)) between morbid obesity (body mass index (BMI) > 40) and in-hospital SAH mortality, and another study found the effect between continuously increasing BMI and both short-term (OR = 0.90 (0.82-0.99)) and long-term SAH mortalities (OR = 0.92 (0.85-0.98)). However, according to our quality assessment, methodological shortcomings expose all reviewed studies to a high-risk-of-bias. Even though two studies suggest that obesity may protect SAH patients from death in the acute phase, all reviewed studies suffered from methodological shortcomings that have been typical in the research field of obesity paradox. Therefore, no definite conclusions could be drawn.

Low body mass index negatively affects muscle mass and intramuscular fat of chronic stroke survivors

Objective

Relationship between secondary changes in skeletal muscle and body weight in chronic stroke survivors has not yet been carefully examined. The objective of this study was to clarify the relationships between muscle mass, intramuscular fat, and body weight in chronic stroke survivors.

Methods

Seventy-two chronic stroke survivors participated in this study. Transverse ultrasound images were acquired using B-mode ultrasound imaging. Quadriceps muscle mass and intramuscular fat were assessed based on muscle thickness and echo intensity, respectively. We used a stepwise multiple regression analysis to identify the factors that were independently associated with the body mass index. We entered quadriceps thickness and echo intensity of the paretic and non-paretic sides into another stepwise multiple regression model to avoid multicollinearity. Age, sex, type of stroke, time since stroke, thigh length, number of medications, and an updated Charlson comorbidity index were included as the independent variables.

Results

The quadriceps thickness and echo intensity of the paretic and non-paretic sides were significantly independently associated with the body mass index: quadriceps thickness of the paretic side, β = 0.52; quadriceps thickness of the non-paretic side, β = 0.55; quadriceps echo intensity of the paretic side, β = −0.35; quadriceps echo intensity of the non-paretic side, β = −0.27).

Conclusions

Our results suggest that low body mass index is associated with loss of muscle mass and increased intramuscular fat on both the paretic and non-paretic sides of chronic stroke survivors. Further studies examining whether appropriate weight management, along with targeted rehabilitation programs aimed at increasing muscle mass and decreasing intramuscular fat, achieves good outcomes in chronic stroke survivors are warranted.

Does the obesity paradox predict functional outcome in intracerebral hemorrhage?

OBJECTIVEBeing overweight or mildly obese has been associated with a decreased risk of death or hospitalization in patients with cardiovascular disease. Similarly, overweight patients admitted to an intensive care unit (ICU) have improved survival up to 1 year after admission. These counterintuitive observations are examples of the "obesity paradox." Does the obesity paradox exist in patients with intracerebral hemorrhage (ICH)? In this study the authors examined whether there was an association between obesity and functional outcome in patients with ICH.METHODSThe authors analyzed 202 patients admitted to the neurological ICU (NICU) who were prospectively enrolled in the Columbia University ICH Outcomes Project between September 2009 and December 2012. Patients were categorized into 2 groups: overweight (body mass index [BMI] ≥ 25 kg/m2) and not overweight (BMI < 25 kg/m2). The primary outcome was defined as survival with favorable outcome (modified Rankin Scale [mRS] score 0-3) versus death or severe disability (mRS score 4-6) at 3 months.RESULTSThe mean age of the patients in the study was 61 years. The mean BMI was 28 ± 6 kg/m2. The mean Glasgow Coma Scale score was 10 ± 4 and the mean ICH score was 1.9 ± 1.3. The overall 90-day mortality rate was 41%. Among patients with a BMI < 25 kg/m2, 24% (17/70) had a good outcome, compared with 39% (52/132) among those with a BMI ≥ 25 kg/m2 (p = 0.03). After adjusting for ICH score, sex, do-not-resuscitate code status, and history of hypertension, being overweight or obese (BMI ≥ 25 kg/m2) was associated with twice the odds of having a good outcome compared with patients with BMI < 25 kg/m2 (adjusted odds ratio 2.05, 95% confidence interval 1.03-4.06, p = 0.04).CONCLUSIONSIn patients with ICH admitted to the NICU, being overweight or obese (BMI ≥ 25 kg/m2) was associated with favorable outcome after adjustment for established predictors. The reason for this finding requires further study.

Low Body Mass Index is a Poor Prognosis Factor in Cardioembolic Stroke Patients with NonValvular Atrial Fibrillation

BACKGROUND

The relationship between body mass index (BMI) and the severity of cardioembolic stroke (CES) remains poorly understood.

METHOD

A total of 419 consecutive CES patients with nonvalvular atrial fibrillation (NVAF), and with a modified Rankin Scale (mRS) score of 0 or 1 before onset admitted within 48hours after onset to the Hirosaki Stroke and Rehabilitation Center were studied. The patients were divided into three groups, low BMI (L-BMI; n = 36, BMI < 18.5 kg/m²), normal BMI (N-BMI; n = 284, 18.5 ≤ BMI < 25.0), and high BMI (H-BMI; n = 99, BMI ≥ 25.0). We compared stroke severity and functional outcome among the three groups.

RESULTS

Stroke severity on admission, assessed by the National Institutes of Health Stroke Scale (NIHSS) showed that patients with L-BMI had the highest NIHSS score (median, 16 [11-25]), followed by N-BMI and H-BMI (11 [5-19] and 9 [3-19], P = .002). Functional outcome at discharge, assessed by mRS, was most severe in L-BMI patients (5 [3-5]), followed by N-BMI and H-BMI (3 [1-4] and 2 [1-4], P = .001). Multivariate analyses revealed that L-BMI was a significant determinant of severe stroke (NIHSS scores ≥8) at admission (odds ratio [OR] to N-BMI = 2.79, 95% confidence interval [CI], 1.17-7.78, P = .02) and poor functional outcome (mRS scores ≥3) at discharge (OR = 2.53, 95% CI, 1.12-6.31, P = .02). However, H-BMI did not affect stroke severity at admission or functional outcome at discharge.

CONCLUSION

Low BMI is a risk factor for severe stroke on admission and unfavorable functional outcome at discharge in Japanese CES patients with NVAF.

Determining the joint effect of obesity and diabetes on functional disability at 3-months and on all-cause mortality at 1-year following an ischemic stroke

BACKGROUND

Obesity and diabetes mellitus, or diabetes, are independently associated with post-ischemic stroke outcomes (e.g., functional disability and all-cause mortality). Although obesity and diabetes are also associated with post-ischemic stroke outcomes, the joint effect of obesity and diabetes on these post-ischemic stroke outcomes has not been explored previously. The purpose of the current study was to explore whether the effect of obesity on post-ischemic stroke outcomes differed by diabetes status in a cohort of acute ischemic stroke subjects with at least a moderate stroke severity.

METHODS

Data from the Interventional Management of Stroke (IMS) III clinical trial was analyzed for this post-hoc analysis. A total of 656 subjects were enrolled in IMS III and were followed for one year. The joint effects of obesity and diabetes on functional disability at 3-months and all-cause mortality at 1-year were examined.

RESULTS

Of 645 subjects with complete obesity and diabetes information, few were obese (25.74%) or had diabetes (22.64%). Obese subjects with diabetes and non-obese subjects without diabetes had similar odds of functional disability at 3-months following an ischemic stroke (adjusted common odds ratio, 1.038, 95% CI: 0.631, 1.706). For all-cause mortality at 1-year following an ischemic stroke, obese subjects with diabetes had a similar hazard compared with non-obese subjects without diabetes (adjusted hazard ratio, 1.005, 95% CI: 0.559, 1.808). There was insufficient evidence to declare a joint effect between obesity and diabetes on either the multiplicative scale or the additive scale for both outcomes.

CONCLUSIONS

In this post-hoc analysis of data from the IMS III clinical trial of acute ischemic stroke patients with at least a moderate stroke severity, there was not sufficient evidence to determine that the effect of obesity differed by diabetes status on post-ischemic stroke outcomes. Additionally, there was not sufficient evidence to determine that either factor was independently associated with all-cause mortality. Future studies could differentiate between metabolically healthy and metabolically unhealthy patients within BMI categories to determine if the effect of obesity on post-stroke outcomes differs by diabetes status.

Association of higher waist circumference with milder stroke severity in acute ischaemic stroke

OBJECTIVES

Although higher body mass index (BMI) was reported to be associated with increased stroke incidence, having a higher BMI is known to be associated with better clinical outcomes after stroke. However, BMI has shown conflicting associations with baseline stroke severity. The aim of our study was to assess the relationship between waist circumference (WC) at admission and baseline stroke severity among patients with ischaemic stroke.

METHODS

The WC of acute stroke patients was divided into sex-specific quartiles. Baseline stroke severity was categorised as mild [National Institutes of Health Stroke Scale (NIHSS) score 0-4], moderate (NIHSS score 5-10), and severe (NIHSS score ≥11). Multinomial logistic regression was used and reference categories were men or women in the lowest sex-specific WC quartiles who had experienced a mild stroke.

RESULTS

A total of 637 female and 766 male patients were included. The adjusted OR of severe stroke were 1.3 (95% CI, 0.7-2.4) for male patients in the third WC quartile, 0.7 (95% CI, 0.3-1.5) for male patients in the second WC quartile, and 0.4 (95% CI, 0.2-0.8) for male patients in the top WC quartile. The adjusted OR of severe stroke for female patients in the third WC quartile, the second WC quartile, and the top WC quartile were 0.8 (95% CI, 0.4-1.5), 0.4 (95% CI, 0.2-0.9), and 0.7 (95% CI, 0.3-1.3), respectively.

DISCUSSION

Higher WC at admission is associated with milder baseline stroke severity among patients with acute ischaemic stroke.

ABBREVIATIONS

BMI: body mass index; CE: cardioembolism; CI: confidence interval; LAA: large-artery atherosclerosis; NIHSS: National Institutes of Health Stroke Scale; OR: odds ratio; SAO: small-artery occlusion; WC: waist circumference.

Racial differences in intracerebral haemorrhage outcomes in patients with obesity

OBJECTIVE

This study was conducted to determine the role of obesity and race in intracerebral haemorrhage (ICH) outcomes.

METHODS

The Get with the guideline-Stroke database was queried for all admitted patients with spontaneous ICH. Secondary causes of ICH were excluded. Body mass index (BMI) was classified using the Center for Disease Control guidelines. Race was classified as White or non-White. Demographics, clinical, imaging data were retrieved. Outcome measures were hematoma expansion at 24 h and discharge disposition.

RESULTS

A total of 428 patients were included in our analysis. Female gender, past history of congestive heart failure, diabetes mellitus, HbA1c, blood pressure, ICH volume, ICH location, intraventricular haemorrhage and hospital length of stay deferred across BMI categories. On multivariate analysis, along with obese categories, age, ICH location and ICH volume were independent predictors of poor outcomes (hematoma expansion and poor discharge disposition). After adjusting for these variables, obesity remained a predictor of poor disposition outcome compared with normal and overweight subjects; Normal vs. Obese OR 0.26 CI 0.115-0.593 p = 0.0014; Obese vs. Overweight OR 3.79 CI 1.68-8.52 p = 0.0013. Nonetheless, obesity did not influence hematoma expansion. Overall, BMI-race classification did not influence outcomes. However, among non-Whites, the obese category had higher odds of a poor disposition outcome than normal (OR 6.84 CI 2.12-22.22 p = 0.0013) or overweight (OR 8.45 CI 2.6-27.49 p = 0.0004) categories.

CONCLUSION

An obesity paradox in ICH was not observed in our cohort. In the non-White population, patients with obesity were likely to be associated with poor disposition outcome. Similar findings were not observed in White population.

No correlation between body mass index and 30-day prognostic outcome in Asians with acute ST-elevation myocardial infarction undergoing primary coronary intervention

BACKGROUND

This study investigated whether body mass index (BMI) was a risk factor predictive of 30-day prognostic outcome in Asians with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

MATERIAL AND METHODS

Data regarding the impact of BMI on the prognostic outcome in Asian populations after acute STEMI is scarce. A number of 925 STEMI patients were divided into three groups according to the BMI: normal weight (<25 kg/m²), overweight (≥25.0 to <30.0 kg/m²) and obese (≥30.0 kg/m²).

RESULTS

The obese group was significantly younger with significantly higher incidences of smoking and diabetes mellitus. The incidences of multi-vessel disease, final thrombolysis in myocardial infarction (TIMI)-3 flow, advanced Killip score, advance congestive heart failure, 30-day mortality and combined 30-day major adverse clinical outcome (MACO) did not differ among the three groups. Multiple regression analysis showed the age, unsuccessful reperfusion and lower left ventricular ejection fraction were most significant and independent predictor of 30-day mortality.

CONCLUSION

BMI is not a predictor of 30-day prognostic outcome in Asians with STEMI undergoing primary PCI.

Physical activity, but not body mass index, predicts less disability before and after stroke

OBJECTIVE

To determine whether physical activity and body mass index (BMI) predict instrumental or basic activities of daily living (I/ADL) trajectories before or after stroke compared to individuals who remained stroke-free.

METHODS

Using a prospective cohort, the Health and Retirement Study, we followed adults without a history of stroke in 1998 (n = 18,117) for up to 14 years. We estimated linear regression models of I/ADL trajectories comparing individuals who remained stroke-free throughout follow-up (n = 16,264), those who survived stroke (n = 1,374), and those who died after stroke and before the next interview wave (n = 479). We evaluated whether I/ADL trajectories differed by physical activity or BMI at baseline (before stroke), adjusting for demographic and socioeconomic covariates.

RESULTS

Compared to those who were physically active, stroke survivors who were physically inactive at baseline had a lower probability of independence in ADLs and IADLs 3 years after stroke (risk difference = -0.18 and -0.16 for ADLs and IADLs, respectively). However, a similar difference in the probability of independence was also present 3 years before stroke, and we observed no evidence that physical activity slowed the rate of decline in independence before or after stroke. Unlike the results for physical activity, we did not observe a consistent pattern for the probability of independence in ADLs or IADLs comparing obese stroke survivors to normal-weight or to overweight stroke survivors 3 years before stroke or 3 years after stroke.

CONCLUSIONS

Physical inactivity predicts a higher risk of being dependent both before and after stroke.

Obesity paradox in stroke - Myth or reality? A systematic review

Background and purpose

Both stroke and obesity show an increasing incidence worldwide. While obesity is an established risk factor for stroke, its influence on outcome in ischemic stroke is less clear. Many studies suggest a better prognosis in obese patients after stroke (“obesity paradox”). This review aims at assessing the clinical outcomes of obese patients after stroke by performing a systematic literature search.

Methods

The reviewers searched MEDLINE from inception to December 2015. Studies were eligible if they included outcome comparisons in stroke patients with allocation to body weight.

Results

Twenty-five studies (299’750 patients) were included and none was randomised. Ten of 12 studies (162’921 patients) reported significantly less mortality rates in stroke patients with higher BMI values. Seven of 9 studies (92’718 patients) ascertained a favorable effect of excess body weight on non-fatal outcomes (good clinical outcome, recurrence of vascular events). Six studies (85’042 patients) indicated contradictory results after intravenous thrombolysis (IVT), however. Several methodological limitations were observed in major part of studies (observational study design, inaccuracy of BMI in reflecting obesity, lacking body weight measurement, selection bias, survival bias).

Conclusion

Most observational data indicate a survival benefit of obese patients after stroke, but a number of methodological concerns exist. No obesity paradox was observed in patients after IVT. There is a need for well-designed randomized controlled trials assessing the effects of weight reduction on stroke risk in obese patients.

Association of high waist-to-height ratio with functional outcomes in patients with acute ischemic stroke: A report from the ACROSS-China study

The aim of our study was to investigate the relationship between the waist-to-height ratio (WHR) and all-cause mortality and functional outcomes after acute ischemic stroke in a prospective cohort study.A total of 2076 patients (36.66% females) with ischemic stroke were analyzed from ACROSS-China, which is a nationwide, prospective, hospital-based stroke registry aimed to detect the glucose abnormality in China. One-year follow-up evaluation was done by telephone interview. Outcome measures were all-cause mortality and functional outcome defined as modified Rankin score being 6 and from 0 to 6, respectively. We identified predictors for functional outcomes using logistic regression analysis, and mortality outcome using Cox proportional hazards model which incorporated covariates with P value of < 0.2 in the univariate analysis and those of clinical importance.The higher WHR was associated with worse functional outcome, but not predictive of the patients' mortality outcomes. Compared with the first quartile (≤0.48), the fourth quartile of the WHR was more likely to be associated with poor functional recovery (fourth quartile (≥0.56), OR = 1.38, CI: 1.08-1.77, P = 0.01; third quartile OR = 1.10, CI: 0.86-1.40, P = 0.45; second quartile OR = 1.05, CI: 0.83-1.33, P = 0.71).Our findings suggest that abdominal fat accumulation may be associated with functional recovery after stroke, and is not associated with mortality after stroke. Compared with the lowest quartile, the highest quartile of WHR at admission was possibly associated with worse postacute ischemic stroke functional recovery.

Healthy Lifestyle and Functional Outcomes from Stroke in Women

PURPOSE

While a healthy lifestyle has been associated with reduced risk of developing ischemic stroke, less is known about its effect on stroke severity.

METHODS

We performed a prospective cohort study among 37,634 women without stroke or missing risk factor data at baseline. The healthy lifestyle index was composed of smoking, physical activity, body mass index, alcohol consumption, and diet (range 0-20, with 20 representing healthiest lifestyle). Possible functional outcomes were no stroke or stroke with modified Rankin Scale score of 0-1 (mild), 2-3 (moderate), or 4-6 (severe). Multinomial logistic regression was used to analyze the association between healthy lifestyle and functional outcomes from stroke.

RESULTS

Over 17.2 years of follow-up, 867 total strokes were confirmed. Compared with the lowest category (0-4), the highest category (17-20) was associated with reductions in risk of total stroke with mild (odds ratio [OR] 0.43; 95% confidence interval [CI], 0.20-0.90), moderate (OR 0.53; 95% CI, 0.27-1.06), and severe (OR 0.48; 95% CI, 0.20-1.18) functional outcomes. Even a modest healthy lifestyle index (5-8 points) was associated with significant decreases in total stroke with severe and moderate functional outcomes. Similar results were seen for ischemic but not hemorrhagic strokes.

CONCLUSIONS

Highest vs lowest scores on the healthy lifestyle index were associated with reductions in risk of total and ischemic strokes with mild, moderate, and severe functional outcomes among women. The evidence that even modest healthy lifestyle index scores reduced risks of total and ischemic stroke with moderate and severe functional outcomes suggests modest lifestyle changes may reduce risk of disabling stroke events.

Effect of obesity on functional outcomes at 6 months post-stroke among elderly Koreans: a prospective multicentre study

OBJECTIVES

We examined whether obesity based on body mass index (BMI) was a predictor of functional independence measure (FIM) at 6 months after ischaemic stroke onset while adjusting for stroke risk factors and covariates and stratifying by age group.

DESIGN

This is an interim report of the Korean Stroke Cohort for Functioning and Rehabilitation that was designed as a nested case study within a nationwide hospital-based cohort.

SETTING

We identified all patients who were admitted to nine representative hospitals in Korea from 2012 until 2014 under a diagnosis of acute first-ever ischaemic stroke. The hospitals were selected from the metropolitan district, mid-sized cities and a small-sized city.

PARTICIPANTS

The sample included 2057 patients with acute ischaemic stroke who were at least 18 years old.

PRIMARY AND SECONDARY OUTCOME MEASURES

We divided participants into two age levels (<65 and ≥ 65 years). Participants were classified into five groups according to their baseline BMI at admission: underweight (BMI<18.5), normal (18.5 ≤ BMI<23), overweight (23 ≤ BMI<25), obese (25 ≤ BMI<30) and extremely obese (30 ≤ BMI).

RESULTS

The proportion of patients who were aged ≥ 65 years was 55.0%. The proportions of underweight, normal, overweight, obese and extremely obese patients were 2.6%, 24.3%, 29.6%, 37.2% and 6.3%, respectively, in the <65 years group and 5.5%, 34.5%, 27.9%, 28.8% and 3.3%, respectively, in the ≥ 65 years group. In a multiple linear regression, the 6-month FIM after stroke in the elderly group was significantly associated with being extremely obese (7.95, p<0.05) after adjusting for confounding variables. In the <65 years group, the 6-month FIM was not associated with any weight category.

CONCLUSIONS

This nationwide hospital-based cohort study showed that extreme obesity is a predictor of a good 6-month FIM, especially in patients with ischaemic stroke who are at least 65 years of age.