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Chen Z, Lin W, Zhang F, Cao W. Risk Factors and Prognosis Analysis of Upper Gastrointestinal Bleeding in Patients With Acute Severe Cerebral Stroke. J Clin Gastroenterol 2024; 58:440-446. [PMID: 37341702 PMCID: PMC10994183 DOI: 10.1097/mcg.0000000000001877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/22/2023] [Indexed: 06/22/2023]
Abstract
GOALS We aim to explore the relationship between the use of proton pump inhibitors (PPIs) and upper gastrointestinal bleeding (UGIB). We develop a nomogram model to predict mortality in critically ill stroke patients. STUDY This is a retrospective study based on the MIMIC IV database. We extracted clinical information including demographic data, comorbidities, and laboratory indicators. Univariate and multivariable logistic regressions were used to assess and identify risk factors for the occurrence of UGIB and for the in-hospital mortality of critically ill stroke patients. The resulting model was used to construct a nomogram for predicting in-hospital mortality. RESULTS Five thousand seven hundred sixteen patients from the MIMIC-IV database were included in our analysis. UGIB occurred in 109 patients (1.9%), whereas the PPI use rate was as high as 60.6%. Chronic liver disease, sepsis, shock, anemia, and increased level of urea nitrogen were independent risk factors for the occurrence of UGIB in severe stroke patients. We identified age, heart failure, shock, coagulopathy, mechanical ventilation, continuous renal replacement therapy, antiplatelet drugs, anticoagulation, simplified acute physiology score-II, and Glasgow coma score as independent risk factors for in-hospital mortality in severe stroke patients. The C-index for the final nomograms was 0.852 (95% confidence interval: 0.840, 0.864). CONCLUSIONS We found that the overall rate of UGIB in severe stroke patients is low, whereas the rate of PPI usage is high. In our study, PPI was not identified as a risk factor for the occurrence of UGIB and UGIB was not associated with all-cause mortality. More clinical trials are needed to evaluate the benefits of using PPI in critically ill stroke patients.
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Aziz MA, Bojja S, Aziz AA, Javed N, Patel H. Gastrointestinal Bleeding in Patients With Acute Ischemic Stroke: A Literature Review. Cureus 2024; 16:e53210. [PMID: 38425599 PMCID: PMC10902729 DOI: 10.7759/cureus.53210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Stroke is an infarction of the central nervous system (brain, spinal cord, or retina) that results from a disruption in cerebral blood flow either due to ischemia or hemorrhage. Complications of acute stroke are common and include pneumonia, urinary tract infection, myocardial infarction, deep vein thrombosis, and pulmonary embolism, among several others, all of which increase the risk of poor clinical outcomes. Gastrointestinal bleeding is a well-known complication that can occur during the acute phase of stroke. In this review, we have summarized the existing data regarding the incidence, pathophysiology, risk factors, morbidity, mortality, and management strategies for gastrointestinal bleeding in patients with acute ischemic stroke.
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Affiliation(s)
| | - Srikaran Bojja
- Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Ahmed Ali Aziz
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Nismat Javed
- Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Harish Patel
- Gastroenterology and Hepatology, BronxCare Health System, New York City, USA
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Mosconi MG, Capponi A, Paciaroni M. Systemic thrombolysis in patients with acute stroke and active cancer: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:1843-1850. [PMID: 37337013 DOI: 10.1007/s11739-023-03312-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 05/11/2023] [Indexed: 06/21/2023]
Abstract
Cancer patients frequently have concomitant cerebrovascular diseases, which significantly worsen their prognosis. Prospective studies validating intravenous thrombolysis (IVT) safety profile in patients with acute ischemic stroke and active cancer are still lacking. Therefore, we aimed to evaluate IVT's efficacy and safety profile in acute ischemic stroke patients with comorbid active cancer. We included in a meta-analysis all relevant published studies, including patients with acute ischemic stroke with or without active cancer and receiving IVT, according to recommendations for IVT treatment for acute ischemic stroke. The primary outcomes were: any intracerebral hemorrhage, all-cause mortality, and good functional outcome reported as modified Rankin Scale (mRS) ≤ 2 at the end of the scheduled follow-up period. We included 11 studies in the meta-analysis. IVT was not associated with a significant increase in the incidence of intracerebral hemorrhage (OR 1.35; 95% CI 0.85-2.14; I2 76%), nor with a significant increase in death for any cause (OR 1.26; 95% CI 0.91-1.75; I2 71%); furthermore, IVT did not influence mRS between cancer and non-active cancer stroke patients (OR 0.72; 95% CI 0.35-1.49; I2 59%). IVT seems safe and effective in patients with ischemic stroke and concomitant cancer. Due to the low overall quality of the evidence, high-quality randomized controlled trials with adequate sample sizes are needed.
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Affiliation(s)
- Maria Giulia Mosconi
- Internal and Vascular and Emergency Medicine-Stroke Unit, Università degli Studi di Perugia/Azienda Ospedaliera Santa Maria della Misericordia, 06129, Perugia, Italy.
| | - Andrea Capponi
- Emergency Department, University of Florence, Florence, Italy
| | - Maurizio Paciaroni
- Internal and Vascular and Emergency Medicine-Stroke Unit, Università degli Studi di Perugia/Azienda Ospedaliera Santa Maria della Misericordia, 06129, Perugia, Italy
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Abstract
Gastrointestinal (GI) complications are seen in over 50% of ischemic stroke survivors; the most common complications are dysphagia, constipation, and GI bleeding. The bidirectional relationship of the gut-brain axis and stroke has recently gained traction, wherein stroke contributes to gut dysbiosis (alterations in the normal host intestinal microbiome) and gut dysbiosis perpetuates poor functional neurologic outcomes in stroke. It is postulated that the propagation of proinflammatory cells and gut metabolites (including trimethylamine N-oxide and short-chain fatty acids) from the GI tract to the central nervous system play a central role in gut-brain axis dysfunction. In this review, we discuss the known GI complications in acute ischemic stroke, our current knowledge from experimental stroke models for gut-brain axis dysfunction in stroke, and emerging therapeutics that target the gut-brain axis.
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Affiliation(s)
- Heather Y F Yong
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Carlos Camara-Lemarroy
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Canada
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Association of Proton Pump Inhibitor Prophylaxis on Clinical Outcome in Acute Ischemic Stroke in China: A Multicenter Retrospective Cohort Study. J Clin Med 2022; 11:jcm11236881. [PMID: 36498455 PMCID: PMC9740641 DOI: 10.3390/jcm11236881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Overtreatment with proton pump inhibitors (PPIs) in acute ischemic stroke (AIS) patients continues to grow. We aimed to investigate the frequency of PPI prophylaxis without an appropriate indication in AIS patients in China and clarify the association between PPI prophylaxis and long-term prognosis. METHODS Based on a multicenter stroke registry database, neurological outcomes, stroke events, recurrent ischemic strokes, and all-cause death were compared between patients with and without PPI prophylaxis. RESULTS A total of 4542 AIS were included, and 3335 (73.4%) received PPI prophylaxis. Patients with PPI prophylaxis were more likely to have a poor outcome at 1 year than those without PPI prophylaxis (33.3% vs. 25.8%, OR 1.321; 95% CI 1.102-1.584; p = 0.003). No significant differences were found in all-cause death, stroke event, or recurrent ischemic stroke at 1 year between the two groups. After propensity score matching, PPI prophylaxis was still independently associated with a higher rate of poor outcome (30.9% vs. 25.8%, OR 1.432; 95% CI 1.151-1.780; p = 0.001). Sensitivity analysis also showed that PPI prophylaxis increased the rate of a poor outcome in minor strokes or at different durations of PPI prophylaxis. CONCLUSIONS Approximately 3/4 of AIS patients were given PPI prophylaxis during hospitalization, which was associated with a poor long-term outcome.
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Mosconi MG, Capponi A, Pierini P, Caso V, Paciaroni M. Safety and efficacy of intravenous thrombolysis in patients with acute stroke and active cancer: retrospective cohort study. Neurol Sci 2022; 43:4003-4006. [PMID: 35325319 DOI: 10.1007/s10072-022-06026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Maria Giulia Mosconi
- Internal, Vascular and Emergency Medicine-Stroke Unit, Università Degli Studi Di Perugia/Azienda Ospedaliera Santa Maria Della Misericordia, 06129, Perugia, Italy.
| | - Andrea Capponi
- Internal, Vascular and Emergency Medicine-Stroke Unit, Università Degli Studi Di Perugia/Azienda Ospedaliera Santa Maria Della Misericordia, 06129, Perugia, Italy
| | - Patrizia Pierini
- Internal, Vascular and Emergency Medicine-Stroke Unit, Università Degli Studi Di Perugia/Azienda Ospedaliera Santa Maria Della Misericordia, 06129, Perugia, Italy
| | - Valeria Caso
- Internal, Vascular and Emergency Medicine-Stroke Unit, Università Degli Studi Di Perugia/Azienda Ospedaliera Santa Maria Della Misericordia, 06129, Perugia, Italy
| | - Maurizio Paciaroni
- Internal, Vascular and Emergency Medicine-Stroke Unit, Università Degli Studi Di Perugia/Azienda Ospedaliera Santa Maria Della Misericordia, 06129, Perugia, Italy
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Zhang H, Dai W, Kong W, Duan Z, Yun Z, Zhou S, Yang J, Li F, Zi W, Guo Z, Liu W. Effect of Gastrointestinal Hemorrhage on Outcome After Endovascular Treatment in Acute Basilar Artery Occlusion. Front Neurol 2022; 13:809209. [PMID: 35572946 PMCID: PMC9100889 DOI: 10.3389/fneur.2022.809209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background and PurposeGastrointestinal hemorrhage (GIH) is associated with a poorer prognosis and a higher mortality rate after acute ischemic stroke (AIS), but its association with outcomes after endovascular treatment (EVT) remains unclear. This study aimed to assess the incidence, risk factors, and relationships among clinical outcomes of GIH after EVT in patients with acute basilar artery occlusion (BAO).MethodsConsecutive patients treated with EVT were identified from the EVT for Acute Basilar Artery Occlusion Study (BASILAR) registry. All enrolled patients were divided into GIH and non-GIH subgroups, and the independent predictors of GIH after EVT were explored. An ordinal logistic regression model was used to assess the association between GIH and primary outcome [distribution of modified Rankin scale (mRS)] at 90 days, while binary logistic regression models for other outcomes were also employed.ResultsAmong 647 patients with acute BAO, 114 (17.6%) patients experienced GIH after EVT. Higher glucose levels at admission, longer procedure time, and general anesthesia were the independent predictors of GIH after EVT, while protective factors include the posterior circulation-Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) ≥ 5 and a history of hyperlipidemia. Compared with the non-GIH group, the GIH group was associated with a worse functional outcome [adjusted common odds ratio (OR), 2.12 (95% CI, 1.39–3.25)], lower rates of functional independence [adjusted OR,.47 (95% CI, 0.26–0.88)], a favorable outcome [adjusted OR, 0.41 (95% CI, 0.22–0.73)], and a higher risk of 90-day mortality [adjusted OR, 1.76 (95% CI, 1.08–2.85)].ConclusionThis study concluded that GIH is not uncommon after EVT in patients with acute BAO and is associated with worse functional disability and higher mortality.
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Affiliation(s)
- Hao Zhang
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weipeng Dai
- Department of Neurology, Jiangmen Central Hospital, Jiangmen, China
| | - Weilin Kong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhenhui Duan
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Zongjin Yun
- Department of Neurology, Fuyang Hospital of Anhui Medical University, Fuyang, China
| | - Sheng Zhou
- Department of Neurology, Renhuai People's Hospital, Guizhou, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhangbao Guo
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
- *Correspondence: Zhangbao Guo
| | - Wenhua Liu
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
- Wenhua Liu
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Cui P, McCullough LD, Hao J. Brain to periphery in acute ischemic stroke: Mechanisms and clinical significance. Front Neuroendocrinol 2021; 63:100932. [PMID: 34273406 PMCID: PMC9850260 DOI: 10.1016/j.yfrne.2021.100932] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/27/2021] [Accepted: 07/12/2021] [Indexed: 01/21/2023]
Abstract
The social and public health burdens of ischemic stroke have been increasing worldwide. In addition to focal brain damage, acute ischemic stroke (AIS) provokes systemic abnormalities across peripheral organs. AIS profoundly alters the autonomic nervous system, hypothalamic-pituitary-adrenal axis, and immune system, which further yield deleterious organ-specific consequences. Poststroke systemic pathological alterations in turn considerably contribute to the progression of ischemic brain injury, which accounts for the substantial impact of systemic complications on stroke outcomes. This review provides a comprehensive and updated pathophysiological model elucidating the systemic effects of AIS. To address their clinical significance and inform stroke management, we also outline the resulting systemic complications at particular stages of AIS and highlight the mechanisms. Future therapeutic strategies should attempt to integrate the treatment of primary brain lesions with interventions for secondary systemic complications, and should be tailored to patient individualized characteristics to optimize stroke outcomes.
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Affiliation(s)
- Pan Cui
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Louise D McCullough
- Department of Neurology, University of Texas Health Science Centre, Houston, TX 77030, USA
| | - Junwei Hao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.
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He D, Guo Y, Zhang Y, Zhao J, Wu L, Yu Z, Qu W, Luo X. Thromboelastography predicts dual antiplatelet therapy-related hemorrhage in patients with acute ischemic stroke. J Neurointerv Surg 2021; 14:672-676. [PMID: 34326196 PMCID: PMC9209664 DOI: 10.1136/neurintsurg-2021-017615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/11/2021] [Indexed: 12/27/2022]
Abstract
Background Stratification of the risk of hemorrhage in patients with acute ischemic stroke following dual antiplatelet therapy (DAPT) is challenging. It remains unclear whether thromboelastography (TEG) can be used to predict DAPT-related hemorrhagic events. Objective The present study aims to discover predictors for hemorrhage events after DAPT based on parameters such as TEG. Methods A total of 859 patients with acute ischemic stroke who received DAPT were recruited consecutively. Demographic, clinical, and neuroimaging characteristics were evaluated at baseline; TEG parameters were obtained 7 days later after DAPT. Hemorrhagic events were monitored about 1 month after the stroke. Results Of the patients, 61 (7.1%) had hemorrhagic events. Patients in the hemorrhage group had a lower adenosine diphosphate (ADP)-induced platelet-fibrin clot maximum amplitude and a higher ADP inhibition rate (ADP%) than those in the non-hemorrhage group (p<0.05). ADP% was confirmed as an independent predictor of hemorrhagic events with an optimal cut-off point of 83.3% (area under the curve (AUC) = 0.665, 95% CI 0.573 to 0.767, p<0.01). We constructed a logistic model based on D-dimer, National Institutes of Health Stroke Scale scores, and ADP% to predict hemorrhagic events in patients with acute ischemic stroke during DAPT (AUC=0.720, 95% CI 0.625 to 0.858, p<0.01), with a sensitivity of 72.1% and a specificity of 76.5%. Conclusions Monitoring changes of TEG parameters helps to guide personalized DAPT for patients with ischemic stroke. A 30–82.3% range of ADP% is recommended for DAPT treatment.
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Affiliation(s)
- Dan He
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, Guangdong, China
| | - Yinping Guo
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yi Zhang
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jing Zhao
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lingshan Wu
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhiyuan Yu
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wensheng Qu
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiang Luo
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
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Green TL, McNair ND, Hinkle JL, Middleton S, Miller ET, Perrin S, Power M, Southerland AM, Summers DV. Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association. Stroke 2021; 52:e179-e197. [PMID: 33691469 DOI: 10.1161/str.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In 2009, the American Heart Association/American Stroke Association published a comprehensive scientific statement detailing the nursing care of the patient with an acute ischemic stroke through all phases of hospitalization. The purpose of this statement is to provide an update to the 2009 document by summarizing and incorporating current best practice evidence relevant to the provision of nursing and interprofessional care to patients with ischemic stroke and their families during the acute (posthyperacute phase) inpatient admission phase of recovery. Many of the nursing care elements are informed by nurse-led research to embed best practices in the provision and standard of care for patients with stroke. The writing group comprised members of the Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. A literature review was undertaken to examine the best practices in the care of the patient with acute ischemic stroke. The drafts were circulated and reviewed by all committee members. This statement provides a summary of best practices based on available evidence to guide nurses caring for adult patients with acute ischemic stroke in the hospital posthyperacute/intensive care unit. In many instances, however, knowledge gaps exist, demonstrating the need for continued nurse-led research on care of the patient with acute ischemic stroke.
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Huang ZX, Gu HQ, Yang X, Wang CJ, Wang YJ, Li ZX. Risk factors for in-hospital mortality among acute ischemic stroke patients in China: a nationwide prospective study. Neurol Res 2020; 43:387-395. [PMID: 33357098 DOI: 10.1080/01616412.2020.1866356] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: We aimed to investigate factors related to in-hospital mortality (IHM) in acute ischemic stroke (AIS) patients.Methods: We prospectively investigated 827,314 patients who were admitted within 7 days of AIS between August 2015 and July 2019. Demographic characteristics, risk factors, and clinical and laboratory characteristics of patients were assessed. Univariate and multivariate logistic regression analyses were performed to identify predictors associated with IHM.Results: The IHM rate in this study was 0.5% in women and 0.3% in men. Factors associated with IHM in AIS included diabetes (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.03-1.43), female (OR 0.84, 95%CI 0.74-0.96), hypertension (OR 1.16, 95%CI 1.01-1.34), atrial fib/flutter (OR 1.51, 95%CI 1.29-1.77), other heart disease (OR1.43, 95%CI 1.23-1.67), prior myocardial infarction (OR 2.00, 95%CI 1.54-2.60), antiplatelet therapies (OR 0.71, 95%CI 0.60-0.84), gastrointestinal bleeding (OR 3.54, 95%CI 2.83-4.44), pulmonary embolism (OR 2.53, 95%CI1.41-4.53), dysphagia(OR7.32, 95%CI6.23-8.61), glycosylated hemoglobin (OR1.05, 95%CI 1.02-1.09), serum creatinine (OR 1.001, 95%CI 1.001-1.002), urea nitrogen (OR 1.10, 95%CI 1.08-1.12), National Institutes of Health Stroke Scale (NIHSS) score (4-5 vs. 0-4: OR 3.58; ≥15 vs. 0-4: OR 8.78), stroke rehabilitation (OR 0.27, 95%CI 0.23-0.30), age (third IQR vs. first IQR: OR 1.57; fourth IQR vs. first IQR: OR 2.23), and in-hospital stroke/TIArecurrence (OR 2.38, 95%CI 2.03-2.78).Conclusions: The findings from this study may help clinicians control the risk of IHM better for patients with AIS.
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Affiliation(s)
- Zhi-Xin Huang
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China.,Department of Neurology, The Second Clinical Medical College of Southern Medical University, Guangzhou, Guangdong, China
| | - Hong-Qiu Gu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xin Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chun-Juan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong-Jun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zi-Xiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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12
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Du W, Zhao X, Wang Y, Pan Y, Liu G, Wang A, Ji R, Liu L, Gu H, Dong K, Wang P, Wang Y. Gastrointestinal bleeding during acute ischaemic stroke hospitalisation increases the risk of stroke recurrence. Stroke Vasc Neurol 2020; 5:116-120. [PMID: 32606083 PMCID: PMC7337367 DOI: 10.1136/svn-2019-000314] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 01/01/2023] Open
Abstract
Objective Gastrointestinal (GI) bleeding in patients who had a stroke is strongly associated with a higher risk of death and loss of independence. However, it is unknown whether GI bleeding increases risk for recurrence of stroke. In this study, we assess the potential relationship between GI bleeding and stroke recurrence in patients within 12 months of an acute ischaemic stroke (AIS), using the China National Stroke Registry (CNSR). Methods This study included 22 216 patients who had an ischaemic stroke included in the CNSR from 2007 to 2008. We analysed baseline patient characteristics, GI bleeding and outcomes of patients who had an AIS, specifically stroke recurrence at 3, 6 and 12 months. We used multivariable logistic regression to evaluate a possible association between GI bleeding and stroke recurrence. Results Of the 12 415 patients included in our study, 12.3%, 15.5% and 17.7% had a stroke recurrence at 3, 6 and 12 months, respectively. GI bleeding was an independent stroke recurrence risk factor in patients after ischaemic stroke at 3 months (adjusted OR 1.481, 95% CI 1.118 to 1.962), 6 months (adjusted OR 1.448, 95% CI 1.106 to 1.896) and 12 months (adjusted OR 1.350; 95% CI 1.034 to 1.763). Conclusion GI bleeding was associated with the increased risk of stroke recurrence after an AIS.
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Affiliation(s)
- Wanliang Du
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beiing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Gaifen Liu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruijun Ji
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kehui Dong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Penglian Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beiing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
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13
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Imbalance in the force: the dark side of the microbiota on stroke risk and progression. Curr Opin Neurobiol 2019; 62:10-16. [PMID: 31809996 DOI: 10.1016/j.conb.2019.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/26/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022]
Abstract
The composition of the gut microbiota depends on many factors, including our lifestyle, diet, metabolism, antibiotic use and hygiene. The contribution of these factors in shaping the gut microbiota and the subsequent effects on the prevention and development of stroke has been under intense investigation. Furthermore, several reports have uncovered the impact of stroke on intestinal dysfunction and gut dysbiosis, highlighting the delicate interplay between the brain, gut and microbiome following this acute brain injury. Despite our growing appreciation of the gut microbiota in shaping brain health, the immune system, host metabolism and disease progression, its therapeutic capability in stroke is yet to be fully exploited. This review will explore the microbiota-gut-brain axis in stroke, and examine the potential role of the gut microbiota in the onset, progression and recovery phase of stroke.
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Abstract
Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.
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Abstract
Gastrointestinal bleeding (GIB) is a common complication that occurs after stroke, and GIB may negatively affect patient prognosis. In this study, we aimed to examine:(1) the risk factors of GIB in acute cerebral infarction patients;(2) association between GIB and 1-year mortality in patients with acute cerebral infarction.Patients with acute cerebral infarction were divided into 2 groups based on the occurrence of GIB during acute stroke stage. Patient characteristics, clinical presentation, stroke risk factors, comorbidities, laboratory data, medication, and outcomes were investigated to analyze the associations between the variables and the probability of having GIB. In addition, patients in the study were matched individually by age, gender. A 1:1 matched case-control method and conditional logistic regression models for single and multiple factors were used to assess the risk factors of GIB in acute cerebral infarction patients.Clinical data of patients with acute cerebral infarction were reviewed and analyzed during the years 2015 and 2016. Finally, 1662 patients with acute cerebral infarction were included in this study, of whom 139 (8.5%) patients had GIB at admission. Multivariate logistic regression analysis revealed that the independent risk factors for GIB in patients with acute cerebral infarction were advanced age (OR = 1.030, P = .009), low Glasgow Coma Scale (GSC) score (OR = 0.850, P = .014), infection (OR = 4.693, P < .001), high NIHSS score (OR = 1.114, P = .001), and posterior circulation infarction (OR = 4.981, P = .010). The case-control study ultimately included 136 case-control pairs. Stepwise conditional regression analyses revealed that the independent risk factors for GIB in patients with acute cerebral infarction were low Glasgow Coma Scale (GSC) score (RR = 0.645, P = .011), infection (RR = 15.326, P = .001), and posterior circulation infarction (RR = 6.129, P = .045). The group with GIB had a higher rate of mortality and disability level (mRS grade ≥ 4) than the group without GIB (P < .001) within 1 year after stroke. In addition, independent risk factors of death within 1 year after stroke in patients were GIB (OR = 6.096, P < .001), infection (OR = 4.493, P < .001), mRS grade ≥ 4 (OR = 4.129, P < .001), and coronary heart disease (OR = 3.718, P = .001).GIB is a common complication after ischemic stroke. These identified factors may help clinicians identify risks of GIB before it develops. GIB is associated with increased risk of 1-year mortality and poor functional outcome in acute cerebral infarction patients.
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Gastrointestinal Hemorrhage in Patients with Acute Ischemic Stroke: Should Endoscopy Be Within the Scope of Practice? Dig Dis Sci 2019; 64:1395-1396. [PMID: 30734237 DOI: 10.1007/s10620-019-05503-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Siddiqui MT, Bilal M, Gollapudi LA, Mehta D, Umar S, Barsa J, Nabors C, Schorr-Lesnick B, Lebovics E, Tewari V. Endoscopy Is Relatively Safe in Patients with Acute Ischemic Stroke and Gastrointestinal Hemorrhage. Dig Dis Sci 2019; 64:1588-1598. [PMID: 30519853 DOI: 10.1007/s10620-018-5399-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 11/27/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrointestinal hemorrhage (GIH) is reported to occur in 1-8% of patients admitted with acute ischemic stroke (AIS). AIS is considered to be a relative contraindication to GIE. AIMS Evaluate the outcomes of gastrointestinal endoscopy (GIE) in patients hospitalized with AIS and GIH. METHODS Patients hospitalized with AIS and GIH were included from the National Inpatient Sample 2005-2014. Primary outcome measure was in-hospital mortality in patients with AIS and GIH who underwent gastrointestinal endoscopy. Secondary outcomes were (1) resource utilization as measured by length of stay (LOS) and total hospitalization costs and (2) to identify independent predictors of undergoing GIE in patients with AIS and GIH. Confounders were adjusted for by using multivariable regression analysis. RESULTS A total of 75,756 hospitalizations were included in the analysis. Using a multivariate analysis, the in-hospital mortality was significantly lower in patients who underwent GIE as compared to those who did not [aOR: 0.4, P < 0.001]. Patients who underwent GIE also had significantly shorter adjusted mean LOS [adjusted mean difference in LOS: 0.587 days, P < 0.001]. Patients with AIS and GIH who did not undergo GIE had significantly higher adjusted total hospitalization costs. [Mean adjusted difference in total hospitalization costs was $5801 (P < 0.001).] Independent predictors of undergoing GIE in this population were male gender, age > 65 years, Asian or Pacific race, hypovolemic shock, need for blood transfusion and admission to urban non-teaching hospital. CONCLUSIONS Gastrointestinal endoscopy can be safely performed in a substantial number of patients with AIS and GIH.
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Affiliation(s)
| | - Mohammad Bilal
- Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | | | - Dhruv Mehta
- Department of Gastroenterology, New York Medical College, Valhalla, NY, 10595, USA
| | - Shifa Umar
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny Health Network, Pittsburgh, PA, 15212, USA
| | - Jonathan Barsa
- Department of Gastroenterology, New York Medical College, Valhalla, NY, 10595, USA
| | - Christopher Nabors
- Department of Internal Medicine, New York Medical College, Valhalla, NY, 10595, USA
| | - Beth Schorr-Lesnick
- Department of Gastroenterology, New York Medical College, Valhalla, NY, 10595, USA
| | - Edward Lebovics
- Department of Gastroenterology, New York Medical College, Valhalla, NY, 10595, USA
| | - Virendra Tewari
- Department of Gastroenterology, New York Medical College, Valhalla, NY, 10595, USA
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Zhou Y, Xu W, Wang W, Yao S, Xiao B, Wang Y, Chen B. Gastrointestinal Hemorrhage is Associated with Mortality after Acute Ischemic Stroke. Curr Neurovasc Res 2019; 16:135-141. [PMID: 30977448 DOI: 10.2174/1567202616666190412160451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 03/14/2019] [Accepted: 03/18/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Gastrointestinal (GI) hemorrhage is serious during the acute phase and is reported to be related to an increased risk of death during the acute phase of acute ischemic stroke in particular. Our study was designed to investigate the relationship between GI hemorrhage and the mortality of acute ischemic stroke, assessing the influence of cerebrovascular risk factors, brain herniation and oral anticoagulation on the onset of GI hemorrhage. The identified risk factors for the occurrence of GI hemorrhage help to elucidate their respective roles in the mortality of acute ischemic stroke. METHODS A total of 15993 consecutive patients with acute ischemic stroke, including 216 cases and 15777 controls, were enrolled in the study from October 2010 to December 2018. Basic clinical and examination data were collected at the time of study enrollment. GI hemorrhage was diagnosed according to the presence of clinical features and endoscopy. Chi-square test and multiple logistic regressions were conducted to explore the associations between the GI hemorrhage occurrence and known risk factors. Kaplan-Meier was used to assess the influence of GI hemorrhage on the age of mortality of acute ischemic stroke. RESULTS GI hemorrhage cases among patients with acute ischemic stroke accounted for 1.35%. Male patients with ischemic stroke were more likely to have GI hemorrhage than their female counterparts (odds ratio (OR): 1.79; P = 0.000). Patients with atrial fibrillation (AF) had a higher incidence of GI hemorrhage than their counterparts without AF (3.03% vs. 1.20%; P < 0.05). Use of oral anticoagulants was related to increased risk for GI hemorrhage (OR: 1.96; P = 0.00). After adjusting for age and sex, both AF and oral anticoagulant use maintained associations with increased risk for GI hemorrhage (2.59-times and 2.02-times risk respectively; P = 0.00). Patients with hyperlipidemia had a lower incidence of GI hemorrhage than their counterparts without hyperlipidemia (0.62% vs. 1.60%; P < 0.05). Hyperlipidemia was associated with a reduced risk of GI hemorrhage (OR: 0.38, 95% confidence interval (CI): 0.25-0.58; P = 0.00), even after adjusting for age and sex (OR: 0.41; P = 0.00). Patients with brain herniation had a 6.54-times increased risk for GI hemorrhage (P = 0.00). GI hemorrhage was associated with 10.98-fold risk for mortality of acute ischemic stroke (P = 0.00). There was an interaction between GI hemorrhage and brain herniation and increased 26.91-fold risk for the mortality after acute ischemic stroke (P = 0.00). CONCLUSION AF, oral anticoagulant use, brain herniation and male sex increase GI hemorrhage risk, while hyperlipidemia reduces risk. GI hemorrhage itself increases the risk for mortality of acute ischemic stroke. The interaction between GI hemorrhage and brain herniation increased the risk for the mortality after acute ischemic stroke.
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Affiliation(s)
- Yongtao Zhou
- The Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China.,Department of Neurobiology, Beijing Institute of Geriatrics, Xuanwu Hospital of Capital Medical University, Beijing, China.,Key Laboratory on Neurodegenerative Disorders of Ministry of Education, Beijing, China
| | - Weihua Xu
- Gastroenterology Department of Traditional Chinese Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Wei Wang
- Gastroenterology Department of Traditional Chinese Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Shukun Yao
- Gastroenterology Department of Traditional Chinese Medicine, China-Japan Friendship Hospital, Beijing, China.,The Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Bei Xiao
- The Department of Medical Record Room, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yuping Wang
- The Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Biao Chen
- The Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China.,Department of Neurobiology, Beijing Institute of Geriatrics, Xuanwu Hospital of Capital Medical University, Beijing, China.,Key Laboratory on Neurodegenerative Disorders of Ministry of Education, Beijing, China
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Gastrointestinal Hemorrhage after Spontaneous Subarachnoid Hemorrhage: A Single-Center Cohort Study. Sci Rep 2017; 7:13557. [PMID: 29051548 PMCID: PMC5648848 DOI: 10.1038/s41598-017-13707-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/27/2017] [Indexed: 12/18/2022] Open
Abstract
Spontaneous subarachnoid hemorrhage (SAH) is a devastating disease, and gastrointestinal hemorrhage is one of several potential complications of acute strokes. We aim to analyze its prevalence, risk factors, and association with in-hospital prognosis following SAH. A total of 1047 adult patients with a primary diagnosis of spontaneous SAH were retrospectively enrolled. We retrieved medical information from the administrative database utilizing diagnostic and procedure codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Patients with SAH included 418 men and 629 women, and their mean age was 57.2 (standard deviation 14.6) years (range, 18–93 years). Gastrointestinal hemorrhage occurred in 30 of the 1047 patients, accounting for 2.9%. In a multivariate logistic regression model, the independent risk factors for gastrointestinal hemorrhage were liver disease and hydrocephalus. The in-hospital mortality rates were 43.3% and 29.3% in patients with and without gastrointestinal hemorrhage, respectively, but the difference was not statistically significant. In conclusion, the prevalence of gastrointestinal hemorrhage was 2.9% in patients hospitalized for spontaneous SAH. Underlying liver disease and the presence of hydrocephalus were both independent risk factors for this complication, which is a reminder to clinicians to pay increased attention in such cases.
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Chou YF, Weng WC, Huang WY. Association between gastrointestinal bleeding and 3-year mortality in patients with acute, first-ever ischemic stroke. J Clin Neurosci 2017; 44:289-293. [DOI: 10.1016/j.jocn.2017.06.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/19/2017] [Accepted: 06/21/2017] [Indexed: 11/28/2022]
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Rumalla K, Kumar AS, Mittal MK. Gastrointestinal Bowel Obstruction in Acute Ischemic Stroke: Incidence, Risk Factors, and Outcomes in a U.S. Nationwide Analysis of 3,998,667 Hospitalizations. J Stroke Cerebrovasc Dis 2017; 26:2093-2101. [PMID: 28527586 DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 04/21/2017] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The prognosis from acute ischemic stroke (AIS) is worsened by poststroke medical complications. The incidence, risk factors, and outcomes of gastrointestinal bowel obstruction (GIBO) in AIS are not known. METHODS We queried the Nationwide Inpatient Sample (2002-2011) to identify all patients with a primary diagnosis of AIS and subsets with and without a secondary diagnosis of GIBO without hernia. Multivariable analysis was utilized to identify risk factors for GIBO in AIS patients and the association between GIBO, in-hospital complications, and outcomes. RESULTS We identified 16,987 patients with GIBO (.43%) among 3,988,667 AIS hospitalizations and 4.2% of these patients underwent surgery. In multivariable analysis, patients with 75+ years of age were two times as likely to suffer GIBO compared to younger patients (P < .0001). African Americans were 42% more likely to have GIBO compared to Whites (P < .0001). Stroke patients with pre-existing comorbidities (coagulopathy, cancer, blood loss anemia, and fluid/electrolyte disorder) were more likely to experience GIBO (all P < .0001). AIS patients with GIBO were 184% and 39% times more likely to face moderate-to-severe disability and in-hospital death, respectively (P < .0001). GIBO occurrence increased length of stay and total costs by an average of 9.7 days and $22,342 (P < .0001). CONCLUSION GIBO is a rare but burdensome complication of AIS, associated with complications, disability, and mortality. The risk factors identified in this study aim to encourage the monitoring of patients at highest risk for GIBO. The predominant form of stroke-related GIBO is nonmechanical obstruction, although the causative relationship remains unknown.
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Affiliation(s)
- Kavelin Rumalla
- School of Medicine, University of Missouri-Kansas City, Kansas City, Kansas
| | - Ashwath S Kumar
- School of Medicine, University of Missouri-Kansas City, Kansas City, Kansas
| | - Manoj K Mittal
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas.
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