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Krekeler BN, Schieve HJP, Khoury J, Ding L, Haverbusch M, Alwell K, Adeoye O, Ferioloi S, Mackey J, Woo D, Flaherty M, La Rosa FDLR, Demel S, Star M, Coleman E, Walsh K, Slavin S, Jasne A, Mistry E, Kleindorfer D, Kissela B. Health Factors Associated With Development and Severity of Poststroke Dysphagia: An Epidemiological Investigation. J Am Heart Assoc 2024; 13:e033922. [PMID: 38533959 PMCID: PMC11179757 DOI: 10.1161/jaha.123.033922] [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: 12/08/2023] [Accepted: 01/31/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Dysphagia after stroke is common and can impact morbidity and death. The purpose of this population-based study was to determine specific epidemiological and health risk factors that impact development of dysphagia after acute stroke. METHODS AND RESULTS Ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review from the GCNKSS (Greater Cincinnati Northern Kentucky Stroke Study), a representative sample of ≈1.3 million adults from southwestern Ohio and northern Kentucky. Dysphagia status was determined on the basis of clinical assessments and necessity for alternative access to nutrition via nasogastric or percutaneous endoscopic gastrostomy tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and premorbid conditions. Multivariable logistic regression determined factors associated with increased risk of dysphagia. Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed that increased age, Black race, higher National Institutes of Health Stroke Scale score at admission, having a hemorrhagic stroke (versus infarct), and right hemispheric stroke increased the risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower prestroke modified Rankin Scale score, and white matter disease. CONCLUSIONS This study replicated previous findings of variables associated with dysphagia (older age, worse stroke, right-sided hemorrhagic lesions), whereas other variables identified were without clear biological rationale (eg, Black race, history of high cholesterol, and presence of white matter disease) and should be investigated in future studies to determine biological relevance and potential influence in stroke recovery.
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Affiliation(s)
- Brittany N. Krekeler
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of Cincinnati College of MedicineCincinnatiOHUSA
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | | | - Jane Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Mary Haverbusch
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Kathleen Alwell
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Opeolu Adeoye
- Department of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Simona Ferioloi
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Jason Mackey
- Department of NeurologyIndiana University School of MedicineIndianapolisINUSA
| | - Daniel Woo
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Matthew Flaherty
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Felipe De Los Rios La Rosa
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
- Baptist Health South FloridaMiami Neuroscience InstituteMiamiFLUSA
| | - Stacie Demel
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | | | - Elisheva Coleman
- Department of NeurologyUniversity of Chicago MedicineChicagoILUSA
| | - Kyle Walsh
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Sabreena Slavin
- Department of NeurologyUniversity of Kansas Medical CenterKansas CityKSUSA
| | - Adam Jasne
- Department of NeurologyYale School of MedicineNew HavenCTUSA
| | - Eva Mistry
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
- Department of NeurologyUniversity of MichiganAnn ArborMIUSA
| | - Brett Kissela
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
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2
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Darvishi M, Amiri MM, Heidari-Soureshjani S, Sherwin CMT, Mardani-Nafchi H. The Association between Statins Intake and Risk of Post Stroke Pneumonia: A Systematic Review and Meta-Analysis. Curr Rev Clin Exp Pharmacol 2024; 19:285-293. [PMID: 37817662 DOI: 10.2174/0127724328258172230926070748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/02/2023] [Accepted: 08/22/2023] [Indexed: 10/12/2023]
Abstract
AIM This research aimed to examine the relationship between the intake of statins and the risk of post-stroke pneumonia in a systematic review and meta-analysis study. METHODS An extensive search of published articles on March 21st, 2023, was done in several databases, like Web of Science (ISI), PubMed, Cochrane Library, Embase, Scopus, and Google Scholar. The Newcastle Ottawa Scale (NOS) checklist was employed to evaluate the quality of observational studies. Statistical tests (Chi-square test and I2) and graphical techniques (Forest plot) were used to determine whether heterogeneity existed in the meta-analysis studies. Funnel plots and Begg and Egger's tests were used to assess the publication bias. RESULTS Seven studies (5 cohort and 2 case-control studies) were retrieved to examine the association between statins and post-stroke pneumonia. The sample size of the studies compiled in the meta- analysis was obtained to be 68,966 participants. Meta-analysis demonstrated that the overall odds of post-stroke pneumonia in the statin group was equal to 0.87 (95% CI: 0.67 - 1.13; p-value 0.458). Subgroup analysis indicated that the odds of post-stroke pneumonia in the statin group was equal to 0.93 (95% CI: 0.73-1.18; p-value = 0.558) in the cohort studies, and equal to 0.92 (95% CI: 0.37-2.26; p-value = 0.857) in the case-control studies. The examination of the association between the intake of statins and post-stroke pneumonia showed no evidence of publication bias (Begg's test, p-value = 0.368; Eggers test, p-value = 0.282). CONCLUSION In this study, no relationship has been observed between receiving statins and the risk of post-stroke pneumonia.
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Affiliation(s)
- Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Centre (IDTMRC), Department of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohammadian Amiri
- Department of Emergency Medicine, School of Medicine, Babol University of Medical Sciences, Mazandaran, Iran
| | | | - Catherine M T Sherwin
- Pediatric Clinical Pharmacology and Toxicology, Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, One Children's Plaza, Dayton, Ohio, USA
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Krekeler BN, Schieve HJP, Khoury J, Ding L, Haverbusch M, Alwell K, Adeoye O, Ferioloi S, Mackey J, Woo D, Flaherty M, De Los Rios La Rosa F, Demel S, Star M, Coleman E, Walsh K, Slavin S, Jasne A, Mistry E, Kleindorfer D, Kissela B. Health factors associated with development and severity of post-stroke dysphagia: an epidemiological investigation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.29.23294807. [PMID: 37693442 PMCID: PMC10491359 DOI: 10.1101/2023.08.29.23294807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Background and Purpose Dysphagia is a common post-stroke occurrence and has been shown to impact patients' morbidity and mortality. The purpose of this study was to use a large population-based dataset to determine specific epidemiological and patient health risk factors that impact development and severity of dysphagia after acute stroke. Methods Using data from the Greater Cincinnati Northern Kentucky Stroke Study, GCNKSS, involving a representative sample of approximately 1.3 million people from Southwest Ohio and Northern Kentucky of adults (age ≥18), ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review. Dysphagia status was determined based on bedside and clinical assessments, and severity by necessity for alternative access to nutrition via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and pre-morbid conditions. Multivariable logistic regression was used to determine factors associated with increased risk of developing dysphagia. Results Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed: increased age, Black race, higher NIHSS score at admission, having a hemorrhagic stroke (vs infarct), and right hemispheric stroke increased risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower pre-stroke mRS score, and white matter disease. Conclusions This study replicated many previous findings of variables associated with dysphagia (older age, worse stroke, right sided hemorrhagic lesions), while other variables identified were without clear biological rationale (e.g. Black race, history of high cholesterol and presence of white matter disease). These factors should be investigated in future, prospective studies to determine biological relevance and potential influence in stroke recovery.
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4
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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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5
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Park D, Son SI, Kim MS, Kim TY, Choi JH, Lee SE, Hong D, Kim MC. Machine learning predictive model for aspiration screening in hospitalized patients with acute stroke. Sci Rep 2023; 13:7835. [PMID: 37188793 DOI: 10.1038/s41598-023-34999-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/11/2023] [Indexed: 05/17/2023] Open
Abstract
Dysphagia is a fatal condition after acute stroke. We established machine learning (ML) models for screening aspiration in patients with acute stroke. This retrospective study enrolled patients with acute stroke admitted to a cerebrovascular specialty hospital between January 2016 and June 2022. A videofluoroscopic swallowing study (VFSS) confirmed aspiration. We evaluated the Gugging Swallowing Screen (GUSS), an early assessment tool for dysphagia, in all patients and compared its predictive value with ML models. Following ML algorithms were applied: regularized logistic regressions (ridge, lasso, and elastic net), random forest, extreme gradient boosting, support vector machines, k-nearest neighbors, and naïve Bayes. We finally analyzed data from 3408 patients, and 448 of them had aspiration on VFSS. The GUSS showed an area under the receiver operating characteristics curve (AUROC) of 0.79 (0.77-0.81). The ridge regression model was the best model among all ML models, with an AUROC of 0.81 (0.76-0.86), an F1 measure of 0.45. Regularized logistic regression models exhibited higher sensitivity (0.66-0.72) than the GUSS (0.64). Feature importance analyses revealed that the modified Rankin scale was the most important feature of ML performance. The proposed ML prediction models are valid and practical for screening aspiration in patients with acute stroke.
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Affiliation(s)
- Dougho Park
- Department of Medical Science and Engineering, School of Convergence Science and Technology, Pohang University of Science and Technology, Pohang, Republic of Korea.
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea.
| | - Seok Il Son
- Occupational Therapy Department of Rehabilitation Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Min Sol Kim
- Occupational Therapy Department of Rehabilitation Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Tae Yeon Kim
- Speech-Language Therapy Department of Rehabilitation Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Jun Hwa Choi
- Department of Quality Improvement, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Sang-Eok Lee
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Daeyoung Hong
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Mun-Chul Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
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6
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Cui C, Li Q, Li C, Zhao S, Li Y. Statin pretreatment combined with intravenous thrombolysis for ischemic stroke patients: A meta-analysis. J Clin Neurosci 2022; 98:142-148. [PMID: 35180504 DOI: 10.1016/j.jocn.2022.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/25/2022] [Accepted: 02/10/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE For ischemic stroke patients, thrombolysis therapy combined statins might have a better benefit. But difference studies had a debate. The meta-analysis wants to make clear about whether statins could increase effect of therapy or decrease side effect for these patients. METHODS OBJECTIVES To evaluate the effect and safety about using statins in ischemic stroke patients receiving thrombolysis. DATA SOURCES Databases including PubMed, Web of Science, Embase and Cochrane Library. Eligibility criteria: original observational cohort studies. PARTICIPANTS ischemic stroke patients receiving thrombolysis. INTERVENTIONS pretreatment statins. Appraisal and synthesis methods: forest plot to show pooled results; I-squared test to evaluate the heterogeneity. RESULTS Of 87 selected, 8 were eligible. The 8 studies included 10,344 patients (with statins: 2048; without statins: 8296). For clinical recovery at 24 h, pooled OR (odds ratios) was 1.82 (95% CI: 1.49-2.21). For excellent outcome, pooled OR was 1.03 (95% CI: 0.80-1.12). For favorable outcome, pooled OR was 0.99 (95% CI: 0.85-1.16). For ICH (intracranial hemorrhage), pooled OR was 1.16 (95% CI: 0.97-1.40). For sICH (symptomatic intracranial hemorrhage), pooled OR was 1.40 (95% CI: 1.02-1.91). For mortality, overall pooled OR was 0.96 (95% CI: 0.74-1.25). CONCLUSION In conclusion, the meta-analysis found that for ischemic stroke patients receiving thrombolysis, pretreatment statins were related to a better clinical recovery and a lower short-term mortality. Pretreatment statins had no significant relationship with mRS at 90 days and ICH. Pretreatment high dose statins may be related to the occurrence of sICH.
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Affiliation(s)
- Chaohua Cui
- Affiliated Liutie Central Hospital of Guangxi Medical University, Liunan Distract, Liuzhou, Guangxi, China.
| | - Qiang Li
- Affiliated Liutie Central Hospital of Guangxi Medical University, Liunan Distract, Liuzhou, Guangxi, China
| | - Changhong Li
- Affiliated Liutie Central Hospital of Guangxi Medical University, Liunan Distract, Liuzhou, Guangxi, China
| | - Shubin Zhao
- Affiliated Liutie Central Hospital of Guangxi Medical University, Liunan Distract, Liuzhou, Guangxi, China
| | - Yuchuan Li
- Affiliated Liutie Central Hospital of Guangxi Medical University, Liunan Distract, Liuzhou, Guangxi, China
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7
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Yin JH, Peng GS, Chen KH, Chu CM, Chien WC, Kao LT, Wu CC, Yang CW, Tsai WC, Lin WZ, Wu YS, Lin HC, Chang YT. Long-Term Use of Statins Lowering the Risk of Rehospitalization Caused by Ischemic Stroke Among Middle-Aged Hyperlipidemic Patients: A Population-Based Study. Front Pharmacol 2021; 12:741094. [PMID: 34733160 PMCID: PMC8558418 DOI: 10.3389/fphar.2021.741094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/14/2021] [Indexed: 11/27/2022] Open
Abstract
Background: The long-term effects of statin use on rehospitalization due to ischemic stroke (reHospIS) in hyperlipidemic patients are still unknown. Therefore, we aimed to assess the long-term risks of reHospIS for hyperlipidemic patients who were taking statins and nonstatin lipid-lowering medicines on a regular basis. Methods and Materials: The National Health Insurance Research Database in Taiwan was used to conduct a 6-year cohort study of patients >45 years old (n = 9,098) who were newly diagnosed with hyperlipidemia and hospitalized for the first or second time due to ischemic stroke (IS). The risk of reHospIS was assessed using Cox proportional hazards regression model. Results: Nonstatin lipid-lowering medicines regular users were associated with a higher risk of reHospIS compared to stains users (hazard ratio, HR = 1.29–1.39, p < 0.05). Rosuvastatin was the most preferred lipid-lowering medicine with lower HRs of reHospIS in hyperlipidemic patients whether they developed diabetes or not. Bezafibrate regular users of hyperlipidemic patients developing diabetes (HR = 2.15, p < 0.01) had nearly 50% lower reHospIS risks than those without diabetes (HR = 4.27, p < 0.05). Age, gender, drug dosage, comorbidities of diabetes and heart failure (HF), and characteristics of the first hospitalization due to IS were all adjusted in models. Moreover, increasing trends of HRs of reHospIS were observed from Rosuvastatin, nonstatin lipid-lowering medicines, Lovastatin, and Gemfibrozil to Bezafibrate users. Conclusion: Statins were associated with long-term secondary prevention of reHospIS for hyperlipidemic patients. Rosuvastatin seemed to have the best protective effects. On the other hand, Bezafibrate appears to be beneficial for hyperlipidemic patients developing diabetes. Further research into the combination treatment of statin and nonstatin lipid-lowering medicines in hyperlipidemic patients developing diabetes is warranted.
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Affiliation(s)
- Jiu-Haw Yin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Division of Neurology, Department of Internal Medicine, Taipei Veterans General Hospital, Hsinchu Branch, Hsinchu County, Taipei, Taiwan
| | - Giia-Sheun Peng
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Division of Neurology, Department of Internal Medicine, Taipei Veterans General Hospital, Hsinchu Branch, Hsinchu County, Taipei, Taiwan
| | - Kang-Hua Chen
- Associate Professor, School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Associate Research Fellow, Department of Nursing, Chang Gung Memorial Hospital, Tao-Yuan Branch, Taoyuan, Taiwan
| | - Chi-Ming Chu
- School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Department of Surgery, Songshan Branch of Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Division of Biostatistics and Informatics, Department of Epidemiology, School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Department of Public Health, China Medical University, Taichung, Taiwan.,Department of Healthcare Administration and Medical Informatics College of Health Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Li-Ting Kao
- School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Department of Pharmacy Practice, Tri-Service General Hospital, Taipei, Taiwan.,School of Pharmacy, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Chao Wu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Wei Yang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Chiuan Tsai
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Zhi Lin
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Syuan Wu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Hung-Che Lin
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Hualien Armed Forces General Hospital, Hualien, Taiwan
| | - Yu-Tien Chang
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
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8
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Grossmann I, Rodriguez K, Soni M, Joshi PK, Patel SC, Shreya D, Zamora DI, Patel GS, Sange I. Stroke and Pneumonia: Mechanisms, Risk Factors, Management, and Prevention. Cureus 2021; 13:e19912. [PMID: 34984111 PMCID: PMC8713735 DOI: 10.7759/cureus.19912] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 12/28/2022] Open
Abstract
A stroke is a cerebrovascular medical emergency characterized by the sudden loss of neurological function due to interruption to the blood supply. A serious and common complication of stroke is pneumonia. This review article outlined various studies in order to understand the pathogenesis pathways that lead to the development of stroke-associated pneumonia, as well as therapeutic and preventive options to reduce pneumonia. The article looked for risk factors that increase the risk of developing pneumonia among stroke patients. In addition, it has reviewed various therapeutic modalities, such as postural modifications, pharmacological treatment, and other unique treatments, in an attempt to find which of them are efficient to decrease the occurrence of pneumonia and which of them are not. The article also attempts to emphasize the importance of early screening for dysphagia among stroke patients and demonstrates the importance of preventive strategies that can be easily implemented, such as routine oral care and behavioral modifications.
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Affiliation(s)
- Idan Grossmann
- Research, Medical University of Silesia Faculty of Medical Sciences, Katowice, POL
| | - Kevin Rodriguez
- Research, Universidad Americana (UAM) Facultad de Medicina, Managua, NIC
| | - Mridul Soni
- Research, Shri Lal Bahadur Shastri Government Medical College, Mandi, IND
| | - Pranay K Joshi
- Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | | | | | - Diana I Zamora
- General Medicine, Universidad de Ciencias Médicas Andrés Vesalio Guzman, San José, CRI
| | - Gautami S Patel
- Internal Medicine, Pramukhswami Medical College, Karamsad, IND
| | - Ibrahim Sange
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Research, KJ Somaiya Medical College, Mumbai, IND
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9
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Guo Y, Guo X, Zhao K, Bao Q, Yang J, Yang M. Statin Use and Outcomes of Patients With Acute Ischemic Stroke Treated With Intravenous Thrombolysis: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:734927. [PMID: 34630305 PMCID: PMC8492958 DOI: 10.3389/fneur.2021.734927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/19/2021] [Indexed: 12/17/2022] Open
Abstract
Background: The data on the relationship between statin use and clinical outcomes after intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) are in controversy. Objective: This systematic review and meta-analysis aimed to evaluate the safety and efficacy of statins administered prior to onset and during hospitalization in patients with AIS treated with IVT. Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception until June 8, 2021. Comparative studies investigating statin effect on intracranial hemorrhage (ICH), functional outcomes, and mortality in adults with AIS treated with IVT were screened. Random-effect meta-analyses of odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were performed. The protocol was registered in PROSPERO (CRD42021254919). Results: Twenty-two observational studies were included, which involved 17,554 patients. The pooled estimates showed that pre-stroke statin use was associated with a higher likelihood of symptomatic ICH (OR 1.31; 95% CI 1.07–1.59; p = 0.008) and any ICH (OR 1.21; 95% CI 1.03–1.43; p = 0.02). However, the pre-stroke statin use was not significantly associated with the 3-month mortality, 3-month favorable functional outcome (FFO, modified Rankin Scale [mRS] score 0–1), and 3-month functional independence (FI; mRS score 0–2). However, in-hospital statin use was associated with a reduced risk of symptomatic ICH (OR 0.46; 95% CI 0.21–1.00; p = 0.045), any ICH (OR 0.51; 95% CI 0.27–0.98; p = 0.04), and 3-month mortality (OR 0.42; 95% CI 0.29–0.62; p < 0.001) and an increased probability of 3-month FFO (OR 1.33; 95% CI 1.02–1.744; p = 0.04) and 3-month FI (OR 1.41; 95% C, 1.11–1.80; p = 0.005). Conclusions: The present systematic review and meta-analysis suggests that in-hospital statin use after IVT may be safe and may have a favorable impact on clinical outcomes, a finding not observed in studies restricted to patients with pre-stroke statin use.
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Affiliation(s)
- Yu Guo
- Graduate School, Qinghai University, Xining, China
| | - Xinmei Guo
- Biomedical Engineering Research Center, Kunming Medical University, Kunming, China
| | - Kai Zhao
- Graduate School, Qinghai University, Xining, China
| | - Qiangji Bao
- Graduate School, Qinghai University, Xining, China
| | - Jincai Yang
- Graduate School, Qinghai University, Xining, China
| | - Mingfei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, China
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10
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Li C, Ma M, Dong S, Hong Y, Bao J, Zhang Y, Gao L, Cui C, Guo J, He L. Statin Treatment in the Acute Phase and the Risk of Post-stroke Pneumonia: A Retrospective Cohort Study. Front Neurol 2021; 12:635079. [PMID: 34552547 PMCID: PMC8450324 DOI: 10.3389/fneur.2021.635079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 08/06/2021] [Indexed: 02/05/2023] Open
Abstract
Background: We aimed to investigate the impact of statin treatment in the acute phase on the risk and severity of post-stroke pneumonia because of the uncertain effects of statins on post-stroke pneumonia. Methods: Consecutive cases of acute ischemic stroke (AIS) between January 2014 and February 2019 were retrospectively analyzed. Additionally, the association of statin treatment in the acute phase with the risk and severity of post-stroke pneumonia was estimated with logistic regression. We registered the present study in the Chinese Clinical Trial Registry (ChiCTR 2000032838). Results: Of the 1,258 enrolled patients, no significant difference was observed in post-stroke pneumonia risk between the two groups (with/without statin treatment in the acute phase) after propensity score matching (35.1 vs. 27.9%, p = 0.155). We did not find statin treatment in the acute phase to significantly increase the risk of post-stroke pneumonia both before and after matched analysis [odds ratio (OR) = 1.51, 95% confidence interval (CI) = 0.85-2.67, p = 0.157; OR = 1.57, 95% CI = 0.77-3.18, p = 0.213, respectively]. In the 271 patients with post-stroke pneumonia, no significant difference was found in its severity between two groups (19.6 vs. 19.4%, p = 0.964). No significant association was found between statin treatment and post-stroke pneumonia severity (OR = 0.95, 95% CI = 0.39-2.31, p = 0.918). Conclusions: There appeared to be no additional benefits of statin treatment in the acute phase for post-stroke pneumonia reduction among AIS patients. Clinical Trial Registration:http://www.chictr.org.cn, identifier: ChiCTR2000032838.
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Affiliation(s)
- Changling Li
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Shuju Dong
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Ye Hong
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Jiajia Bao
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Yang Zhang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Lijie Gao
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Chaohua Cui
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Jian Guo
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Li He
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
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11
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Chaves ML, Gittins M, Bray B, Vail A, Smith CJ. Variation of stroke-associated pneumonia in stroke units across England and Wales: A registry-based cohort study. Int J Stroke 2021; 17:155-162. [PMID: 33724106 PMCID: PMC8821977 DOI: 10.1177/17474930211006297] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Pneumonia is common in stroke patients and is associated with worse clinical outcomes. Prevalence of stroke-associated pneumonia varies between studies, and reasons for this variation remain unclear. We aimed to describe the variation of observed stroke-associated pneumonia in England and Wales and explore the influence of patient baseline characteristics on this variation. Methods Patient data were obtained from the Sentinel Stroke National Audit Programme for all confirmed strokes between 1 April 2013 and 31 December 2018. Stroke-associated pneumonia was defined by new antibiotic initiation for pneumonia within the first seven days of admission. The probability of stroke-associated pneumonia occurrence within stroke units was estimated and compared using a multilevel mixed model with and without adjustment for patient-level characteristics at admission. Results Of the 413,133 patients included, median National Institutes of Health Stroke Scale was 4 (IQR: 2–10) and 42.3% were aged over 80 years. Stroke-associated pneumonia was identified in 8.5% of patients. The median within stroke unit stroke-associated pneumonia prevalence was 8.5% (IQR: 6.1–11.5%) with a maximum of 21.4%. The mean and variance of the predicted stroke-associated pneumonia probability across stroke units decreased from 0.08 (0.68) to 0.05 (0.63) when adjusting for patient admission characteristics. This difference in the variance suggests that clinical characteristics account for 5% of the observed variation in stroke-associated pneumonia between units. Conclusions Patient-level clinical characteristics contributed minimally to the observed variation of stroke-associated pneumonia between stroke units. Additional explanations for the observed variation in stroke-associated pneumonia need to be explored which could reduce variation in antibiotic use for stroke patients.
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Affiliation(s)
- Ma Lobo Chaves
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Matthew Gittins
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Benjamin Bray
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Andy Vail
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Craig J Smith
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK.,Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
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12
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Post-stroke infection in acute ischemic stroke patients treated with mechanical thrombectomy does not affect long-term outcome. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:452-459. [PMID: 33598019 PMCID: PMC7863840 DOI: 10.5114/aic.2020.101771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/04/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction The impact of an infection that requires antibiotic treatment (IRAT) after an acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT) remains unclear. Aim Here, we studied the prevalence and the profile of IRAT in patients with AIS treated with MT, aiming to identify predictive factors and prognostic implications at 90 days after stroke. Material and methods We analyzed parameters available within 24 h after AIS including demographics, risk factors, National Institutes of Health Stroke Scale (NIHSS) upon admission and 24 h later, hemorrhagic transformation (HT) on computed tomography, and several clinical and biochemical markers. The outcome measures were the modified Rankin Scale (mRS) 0-2 and 90 days post-stroke mortality. Results We included 291 patients; in 184 (63.2%) patients MT was preceded by intravenous thrombolysis (IVT), and 83 (28.5%) patients developed IRAT. Multivariate analysis showed that male sex and hemorrhagic transformation on CT taken 24 h after stroke increased the risk of IRAT. We found that younger age, male sex, lower delta NIHSS, shorter time from stroke onset to groin puncture, better recanalization and a lack of hemorrhagic transformation on CT taken 24 h after stroke favorably affected outcome at day 90. Multivariate analysis showed that older age, higher delta NIHSS, unknown stroke etiology and lack of treatment with IVT were independent predictors of death up to day 90. Infection that required antibiotic treatment did not enter in the models for the studied outcome measures. Conclusions In AIS patients treated with MT, IRAT is not an independent factor that affects favorable outcome or mortality 90 days after stroke.
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13
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Derbisz J, Nowak K, Wnuk M, Pulyk R, Jagiella J, Slowik J, Dziedzic T, Slowik A. Prognostic Significance of Stroke-Associated Infection and other Readily Available Parameters in Acute Ischemic Stroke Treated by Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2020; 30:105525. [PMID: 33338755 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105525] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/15/2020] [Accepted: 11/29/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The impact of contracting stroke-associate infection (SAI) that requires antibiotic treatment after an acute ischemic stroke (AIS) treated with alteplase remains unclear. We studied the profiles of SAI in patients with AIS treated with alteplase toward identifying predictive factors and prognostic implications at 90 days post-stroke. METHODS We analyzed 33 parameters readily available within 24 hours after AIS: demographics, risk factors, and several clinical and biochemical parameters. Outcome measures were mRS ≤ 2 and mortality 90 days post-stroke. RESULTS 83 (23.6%) of 352 patients developed SAI. Multivariate logistic regression analysis showed that atrial fibrillation, mRS above 0 pre-stroke, lower delta NIHSS (the difference between NIHSS score measured upon admission and 24 hours after later), CRP≥10 mg/L, and elevated WBC count affected SAI risk (model including CRP levels and WBC count) and atrial fibrillation, mRS above 0 pre-stroke, lower delta NIHSS, HT, and elevated fibrinogen levels affected SAI risk (model excluding CRP levels and WBC count). 231 patients (74.1%) had mRS ≤ 2 at day 90. Multivariate logistic regression analysis showed that younger age, no hypertension, mRS=0 pre-stroke, higher delta NIHSS, no HT, no SAI, and CRP<10 mg/L, were associated with mRS≤2 at day 90. 54 (15.3%) patients died within 90 days. Multivariate logistic regression analysis showed that pre-stroke mRS>0, lower delta NIHSS, HT, CRP≥10 mg/L, lower triglyceride levels affected the risk of death within 90 days. CONCLUSIONS Several markers available within 24 hours post-stroke were predictive of SAI that requires antibiotic treatment. SAI affects long-term outcome but not mortality.
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Affiliation(s)
- Justyna Derbisz
- Department of Neurology, University Hospital, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Klaudia Nowak
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Marcin Wnuk
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Roman Pulyk
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Jeremiasz Jagiella
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Joanna Slowik
- Department of Dental Prophylaxis and Experimental Dentistry, Jagiellonian University Medical College, Montelupich 4 Str., 31-155 Krakow, Poland
| | - Tomasz Dziedzic
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland.
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14
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Liu J, Wang Q, Ye C, Li G, Zhang B, Ji Z, Ji X. Premorbid Use of Statin and Outcome of Acute Ischemic Stroke After Intravenous Thrombolysis: A Meta-Analysis. Front Neurol 2020; 11:585592. [PMID: 33281723 PMCID: PMC7688895 DOI: 10.3389/fneur.2020.585592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/16/2020] [Indexed: 01/01/2023] Open
Abstract
Background: The association between the premorbid use of statin and the early outcomes of acute ischemic stroke (AIS) after intravenous thrombolysis (IVT) remains uncertain. We performed a meta-analysis of observational studies to evaluate the influence of the premorbid use of statin on functional outcome and symptomatic intracranial hemorrhage (SIH) in AIS after IVT. Methods: Relevant studies were identified by search of PubMed, Embase, and Cochrane's Library databases. Only studies with multivariate analyses were included. A random-effect model, incorporating inter-study heterogeneity, was used to pool the results. Results: Twenty observational studies with 20,752 AIS patients who were treated with IVT were included. The pooled results showed that the premorbid use of statin was not associated with improved 3-month favorable functional outcome [odds ratio (OR): 1.05, 95% confidence interval (CI): 0.87-1.26, p = 0.60, I 2 = 52%), 3-month functional independence (OR: 1.13, 95% CI: 0.96-1.33, p = 0.15, I 2 = 52%), or 3-month mortality (OR: 1.12, 95% CI: 0.94-1.34, p = 0.20, I 2 = 20%). Moreover, the premorbid use of statin was associated with an increased risk of SIH in AIS after IVT (OR: 1.48, 95% CI: 1.12-1.95, p = 0.006, I 2 = 60%). Subgroup analyses according to study design, adjustment of baseline low-density lipoprotein cholesterol, and definitions of SIH showed consistent results (p-values for subgroup difference all >0.05). Conclusions: The premorbid use of statin is not associated with improved functional outcomes or mortality but is associated with a higher risk of SIH in AIS patients after IVT.
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Affiliation(s)
- Jia Liu
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qinghai Wang
- Department of Cardiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chaoqun Ye
- Department of Rehabilitation Medicine, Airforce Medical Center, Air Force Medical University, Beijing, China
| | - Gaifen Li
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bowei Zhang
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhili Ji
- China-America Institute of Neuroscience, Luhe Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
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15
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Song TJ, Kim J. Effect of Statins on the Risk of Poststroke Pneumonia: National Population-Based Cohort Study. Infect Drug Resist 2020; 13:2689-2698. [PMID: 32982323 PMCID: PMC7493019 DOI: 10.2147/idr.s258420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/12/2020] [Indexed: 12/28/2022] Open
Abstract
Purpose Statins are widely prescribed medications for treatment of dyslipidemia and prevention of cardiovascular disease. Beyond their lipid-lowering property, statins exhibit multiple pleiotropic and antimicrobial effects. We aimed to investigate the effect of statins on the long-term risk of pneumonia after acute ischemic stroke. Methods This retrospective observational research was performed using South Korean National Health Insurance Service claim data, which consist of population-based random sampling. We included patients discharged with acute ischemic stroke (I63 in the ICD10) and no prior history of pneumonia. The primary outcome measure was the occurrence of pneumonia determined based on ICD10 code J09–J18. Treatment with statins during follow-up was collected as a time-dependent variable based on prescription records. Results A total of 7,001 subjects with acute ischemic stroke and no prior history of pneumonia were included. During the mean 3.96-year follow-up, pneumonia occurred in 1,715 subjects (24.5%). On multivariate time-dependent Cox proportional hazard–regression analyses, significant preventive benefit of treatment with statins against pneumonia was noted (adjusted HR 0.86, 95% CI 0.77–0.97). Compared to no use of statin, adjusted HRs (95% CIs) for current use of low–intermediate high-intensity statins were 0.88 (0.78–0.99) and 0.49 (0.27–0.87), respectively. Conclusion Our retrospective national cohort study found reduced risk of poststroke pneumonia with statin therapy after acute ischemic stroke. Our study suggests that treatment with statins may have a preventive effect against the common complication of poststroke pneumonia.
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Affiliation(s)
- Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul 07804, South Korea
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin 16995, South Korea.,Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam 13496, South Korea
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16
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Zhao W, Xiao ZJ, Zhao SP. The Benefits and Risks of Statin Therapy in Ischemic Stroke: A Review of the Literature. Neurol India 2020; 67:983-992. [PMID: 31512619 DOI: 10.4103/0028-3886.266274] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Statins are effective cholesterol-lowering drugs for reducing the risks of mortality and morbidity of cardiovascular diseases. Increasing evidence has shown that statin use is associated with a significant beneficial effect in patients with ischemic stroke. Both pre-stroke and post-stroke statin use has been found to be beneficial in ischemic stroke. Furthermore, good adherence is associated with a better clinical outcome, and statin withdrawal is associated with a poor functional outcome in patients with ischemic stroke. High-intensity statin therapy is advocated for the treatment of ischemic stroke. However, there are concerns regarding the adverse effects associated with statin use in ischemic stroke such as intracranial hemorrhage. In this review, we summarize the beneficial effect of statin use in ischemic stroke and discuss the potential risks associated with statin therapy.
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Affiliation(s)
- Wang Zhao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Zhi-Jie Xiao
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Shui-Ping Zhao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
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17
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Statin, cholesterol, and sICH after acute ischemic stroke: systematic review and meta-analysis. Neurol Sci 2019; 40:2267-2275. [PMID: 31267305 DOI: 10.1007/s10072-019-03995-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE Conflicts exist regarding relationship between prior/new statin use, cholesterol, and early poststroke intracranial hemorrhage (ICH) in acute ischemic stroke (AIS) patients. This meta-analysis is aimed at evaluating the safety of prior/new statin use, cholesterol level and risk of ICH in AIS patients. METHODS We searched PubMed and Embase for studies examining relation between statin use, cholesterol level, and early poststroke ICH in AIS. Included studies should report risk of early poststroke symptomatic ICH (sICH) or overall ICH. A random-effects model was used to pool the data. RESULTS Twenty-five articles involving 26,327 participants were included, among whom 925 had sICH. Prior statin use was not associated with overall ICH (adjusted odds ratio (OR), 1.478; 95% confidence interval (CI), 0.924-2.362; p = 0.103) and sICH in patients who received thrombolysis (adjusted OR, 1.567; 95% CI, 0.994-2.471; p = 0.053) or overall ICH in patients, most of whom had not received recanalization therapy (crude OR, 1.342; 95% CI, 0.872-2.065; p = 0.181). New statin use was associated with decreased sICH after recanalization therapy (crude OR, 0.292; 95% CI, 0.168-0.507; p < 0.001).Cholesterol level was not associated with overall ICH. CONCLUSION Prior/new statin use and lower cholesterol level are not risk factors for sICH and overall ICH in AIS patients, whether or not the patient has received recanalization therapy. New statin use is likely associated with decreased sICH.
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18
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Smith CJ, Heal C, Vail A, Jeans AR, Westendorp WF, Nederkoorn PJ, van de Beek D, Kalra L, Montaner J, Woodhead M, Meisel A. Antibiotic Class and Outcome in Post-stroke Infections: An Individual Participant Data Pooled Analysis of VISTA-Acute. Front Neurol 2019; 10:504. [PMID: 31156537 PMCID: PMC6527959 DOI: 10.3389/fneur.2019.00504] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/26/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction: Antibiotics used to treat post-stroke infections have differing antimicrobial and anti-inflammatory effects. Our aim was to investigate whether antibiotic class was associated with outcome after post-stroke infection. Methods: We analyzed pooled individual participant data from the Virtual International Stroke Trials Archive (VISTA)-Acute. Patients with ischemic stroke and with an infection treated with systemic antibiotic therapy during the first 2 weeks after stroke onset were eligible. Antibiotics were grouped into eight classes, according to antimicrobial mechanism and prevalence. The primary analysis investigated whether antibiotic class for any infection, or for pneumonia, was independently associated with a shift in 90 day modified Rankin Scale (mRS) using ordinal logistic regression. Results: 2,708 patients were eligible (median age [IQR] = 74 [65 to 80] y; 51% female; median [IQR] NIHSS score = 15 [11 to 19]). Pneumonia occurred in 35%. Treatment with macrolides (5% of any infections; 9% of pneumonias) was independently associated with more favorable mRS distribution for any infection [OR (95% CI) = 0.59 (0.42 to 0.83), p = 0.004] and for pneumonia [OR (95% CI) = 0.46 (0.29 to 0.73), p = 0.001]. Unfavorable mRS distribution was independently associated with treatment of any infection either with carbapenems, cephalosporins or monobactams [OR (95% CI) = 1.62 (1.33 to 1.97), p < 0.001], penicillin plus β-lactamase inhibitors [OR (95% CI) = 1.26 (1.03 to 1.54), p = 0.025] or with aminoglycosides [OR (95% CI) = 1.73 (1.22 to 2.46), p = 0.002]. Conclusion: This retrospective study has several limitations including effect modification and confounding by indication. Macrolides may have favorable immune-modulatory effects in stroke-associated infections. Prospective evaluation of the impact of antibiotic class on treatment of post-stroke infections is warranted.
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Affiliation(s)
- Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, United Kingdom.,Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Calvin Heal
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Andy Vail
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Adam R Jeans
- Division of Clinical Support Services and Tertiary Medicine, Department of Microbiology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Willeke F Westendorp
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Lalit Kalra
- Clinical Neurosciences, King's College Hospital NHS Foundation Trust London, London, United Kingdom
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d' Hebron Institute of Research, Barcelona, Spain.,Stroke Research Program, Department of Neurology, Institute de Biomedicine of Seville, Hospital Universitario Virgen Macarena, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Mark Woodhead
- Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Andreas Meisel
- Department of Neurology, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité Universitaetsmedizin Berlin, Berlin, Germany
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19
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Ziff OJ, Banerjee G, Ambler G, Werring DJ. Statins and the risk of intracerebral haemorrhage in patients with stroke: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2019; 90:75-83. [PMID: 30150320 DOI: 10.1136/jnnp-2018-318483] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/21/2018] [Accepted: 07/18/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Whether statins increase the risk of intracerebral haemorrhage (ICH) in patients with a previous stroke remains uncertain. This study addresses the evidence of statin therapy on ICH and other clinical outcomes in patients with previous ischaemic stroke (IS) or ICH. METHODS A systematic literature review and meta-analysis was performed in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to assess observational and randomised studies comparing statin therapy with control (placebo or no treatment) in patients with a previous ICH or IS. The risk ratios (RR) for the primary outcome (ICH) and secondary outcomes (IS, any stroke, mortality and function) were pooled using random effects meta-analysis according to stroke subtype. RESULTS Forty-three studies with a combined total of 317 291 patient-years of follow-up were included. In patients with previous ICH, statins had no significant impact on the pooled RR for recurrent ICH (1.04, 95% CI 0.86 to 1.25; n=23 695); however, statins were associated with significant reductions in mortality (RR 0.49, 95% CI 0.36 to 0.67; n=89 976) and poor functional outcome (RR 0.71, 95% CI 0.67 to 0.75; n=9113). In patients with previous IS, statins were associated with a non-significant increase in ICH (RR 1.36, 95% CI 0.96 to 1.91; n=103 525), but significantly lower risks of recurrent IS (RR 0.74, 95% CI 0.66 to 0.83; n=53 162), any stroke (RR 0.82, 95% CI 0.67 to 0.99; n=55 260), mortality (RR 0.68, 95% CI 0.50 to 0.92; n=74 648) and poor functional outcome (RR 0.83, 95% CI 0.76 to 0.91; n=34 700). CONCLUSIONS Irrespective of stroke subtype, there were non-significant trends towards future ICH with statins. However, this risk was overshadowed by substantial and significant improvements in mortality and functional outcome among statin users. TRIAL REGISTRATION NUMBER CRD42017079863.
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Affiliation(s)
- Oliver Jonathan Ziff
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL, London, UK.,The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Gargi Banerjee
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL, London, UK
| | | | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL, London, UK .,The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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20
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Predictors of post-stroke fever and infections: a systematic review and meta-analysis. BMC Neurol 2018; 18:49. [PMID: 29685118 PMCID: PMC5913801 DOI: 10.1186/s12883-018-1046-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 04/13/2018] [Indexed: 01/21/2023] Open
Abstract
Background Fever after stroke is common, and often caused by infections. In the current study, we aimed to test the hypothesis that pneumonia, urinary tract infection and all-cause fever (thought to include at least some proportion of endogenous fever) have different predicting factors, since they differ regarding etiology. Methods PubMed was searched systematically for articles describing predictors for post-stroke pneumonia, urinary tract infection and all-cause fever. A total of 5294 articles were manually assessed; first by title, then by abstract and finally by full text. Data was extracted from each study, and for variables reported in 3 or more articles, a meta-analysis was performed using a random effects model. Results Fifty-nine articles met the inclusion criteria. It was found that post-stroke pneumonia is predicted by age OR 1.07 (1.04–1.11), male sex OR 1.42 (1.17–1.74), National Institutes of Health Stroke Scale (NIHSS) OR 1.07 (1.05–1.09), dysphagia OR 3.53 (2.69–4.64), nasogastric tube OR 5.29 (3.01–9.32), diabetes OR 1.15 (1.08–1.23), mechanical ventilation OR 4.65 (2.50–8.65), smoking OR 1.16 (1.08–1.26), Chronic Obstructive Pulmonary Disease (COPD) OR 4.48 (1.82–11.00) and atrial fibrillation OR 1.37 (1.22–1.55). An opposite relation to sex may exist for UTI, which seems to be more common in women. Conclusions The lack of studies simultaneously studying a wide range of predictors for UTI or all-cause fever calls for future research in this area. The importance of new research would be to improve our understanding of fever complications to facilitate greater vigilance, monitoring, prevention, diagnosis and treatment.
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Righy C, do Brasil PEA, Vallés J, Bozza FA, Martin-Loeches I. Systemic antibiotics for preventing ventilator-associated pneumonia in comatose patients: a systematic review and meta-analysis. Ann Intensive Care 2017. [PMID: 28620893 PMCID: PMC5472643 DOI: 10.1186/s13613-017-0291-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Early-onset ventilator-associated pneumonia (EO-VAP) is the leading cause of morbidity and mortality in comatose patients. However, VAP prevention bundles focus mainly on late-onset VAP and may be less effective in preventing EO-VAP in comatose patients. Systemic antibiotic administration at the time of intubation may have a role in preventing EO-VAP. Therefore, we evaluated the effectiveness of systemic antibiotic administration in VAP prevention in comatose patients through a systematic review and meta-analysis. METHODS We searched for studies published through December 2015 that evaluated systemic antibiotic prophylaxis in comatose patients. Two authors independently selected and evaluated full-length reports of randomized clinical trials or prospective cohorts in patients aged >16 years that evaluated the impact of systemic antibiotics at the time of intubation on EO-VAP compared to placebo or no prophylaxis. The outcome variables were the incidence of EO-VAP, the duration of mechanical ventilation, ICU length of stay, and ICU mortality. RESULTS We identified 10,988 citations, yielding 26 articles for further analysis; three studies with 267 patients were finally analyzed. Most patients (n = 135) were comatose due to head trauma. Systemic antibiotic administration was associated with decreased incidence of EO-VAP (RR 0.32; 95% CI 0.19-0.54) and shorter ICU LOS (standardized mean difference -0.32; 95% CI -0.56 to -0.08), but had no effect on mortality (RR 1.03; 95% CI 0.7-1.53) or duration of mechanical ventilation (standardized mean difference -0.16; 95% CI -0.41 to 0.08). CONCLUSIONS Antibiotic prophylaxis in comatose patients reduced the incidence of EO-VAP and decreased the ICU stay slightly. Future trials are needed to confirm these results.
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Affiliation(s)
- Cássia Righy
- National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil. .,ICU, Paulo Niemeyer Brain Institute, Rio de Janeiro, Brazil.
| | | | - Jordi Vallés
- CIBER Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,Critical Care Center, CIBER Enfermedades Respiratorias, Hospital Sabadell, Sabadell, Spain
| | - Fernando A Bozza
- National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil.,IDOR, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Ignacio Martin-Loeches
- CIBER Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,Department of Clinical Medicine, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust, HRB Clinical Research, St James's University Hospital Dublin, Dublin, Ireland.,Irish Centre for Vascular Biology (ICVB), Dublin, Ireland
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22
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Wu YL, Saver JL, Chen PC, Lee JD, Wang HH, Rao NM, Lee M, Ovbiagele B. Effect of statin use on clinical outcomes in ischemic stroke patients with atrial fibrillation. Medicine (Baltimore) 2017; 96:e5918. [PMID: 28151869 PMCID: PMC5293432 DOI: 10.1097/md.0000000000005918] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
It remains unclear whether statin therapy should be applied to ischemic stroke patients with atrial fibrillation. The objective of this study was to clarify whether statin therapy can influence the prognosis in recent ischemic stroke patients with atrial fibrillation.We identified ischemic stroke patients with atrial fibrillation between 2001 and 2011 from Taiwan National Health Insurance Database. Patients not treated with statins during the first 90 days after the index stroke were matched to patients treated with statins in the first 90 days in a 2:1 ratio on the basis of age, sex, hypertension, diabetes mellitus, ischemic heart disease, heart failure, estimated National Institutes of Health Stroke Scale, use of anticoagulant, and year of their entry into the cohort. The primary outcome was the first event of recurrent stroke, and the secondary outcome was in-hospital death.A total of 1546 atrial fibrillation patients with statin therapy in the first 90 days poststroke and 3092 matched atrial fibrillation nonstatin controls were enrolled for this analysis. During the median 2.4-year follow-up, the risk of recurrent stroke was not different between subjects receiving versus not receiving statin therapy (hazard ratios = 1.01, 95% confidence interval 0.88 to 1.15). However, patients with atrial fibrillation receiving statin therapy had a reduced risk for death during any hospitalization throughout the long-term follow-up period (hazard ratios = 0.74, 95% confidence interval 0.61 to 0.89).Among ischemic stroke patients with atrial fibrillation, statin therapy initiated during the acute to subacute poststroke stage did not alter the rate of stroke recurrence but was associated with a decreased rate of in-hospital death.
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Affiliation(s)
- Yi-Ling Wu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch
| | - Jeffrey L. Saver
- Stroke Center, Geffen School of Medicine, University of California, Los Angeles, CA
| | - Pei-Chun Chen
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch
| | - Hui-Hsuan Wang
- Department of Healthcare Management, Chang Gung University, Taoyuan, Taiwan
| | - Neal M. Rao
- Stroke Center, Geffen School of Medicine, University of California, Los Angeles, CA
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch
| | - Bruce Ovbiagele
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, SC
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23
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In vivo observations and in vitro experiments on the oral phase of swallowing of Newtonian and shear-thinning liquids. J Biomech 2016; 49:3788-3795. [PMID: 27823802 DOI: 10.1016/j.jbiomech.2016.10.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 09/30/2016] [Accepted: 10/09/2016] [Indexed: 11/21/2022]
Abstract
In this study, an in vitro device that mimics the oral phase of swallowing is calibrated using in vivo measurements. The oral flow behavior of different Newtonian and non-Newtonian solutions is then investigated in vitro, revealing that shear-thinning thickeners used in the treatment of dysphagia behave very similar to low-viscosity Newtonian liquids during active swallowing, but provide better control of the bolus before the swallow is initiated. A theoretical model is used to interpret the experimental results and enables the identification of two dynamical regimes for the flow of the bolus: first, an inertial regime of constant acceleration dependent on the applied force and system inertia, possibly followed by a viscous regime in which the viscosity governs the constant velocity of the bolus. This mechanistic understanding provides a plausible explanation for similarities and differences in swallowing performance of shear-thinning and Newtonian liquids. Finally, the physiological implications of the model and experimental results are discussed. In vitro and theoretical results suggest that individuals with poor tongue strength are more sensitive to overly thickened boluses. The model also suggests that while the effects of system inertia are significant, the density of the bolus itself plays a negligible role in its dynamics. This is confirmed by experiments on a high density contrast agent used for videofluoroscopy, revealing that rheologically matched contrast agents and thickener solutions flow very similarly. In vitro experiments and theoretical insights can help designing novel thickener formulations before clinical evaluations.
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24
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Matz K, Seyfang L, Dachenhausen A, Teuschl Y, Tuomilehto J, Brainin M. Post-stroke pneumonia at the stroke unit - a registry based analysis of contributing and protective factors. BMC Neurol 2016; 16:107. [PMID: 27430328 PMCID: PMC4949772 DOI: 10.1186/s12883-016-0627-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 06/17/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND To investigate prevalence and risk factors for post stroke pneumonia (PSP) in patients with acute ischemic stroke treated at stroke units (SU). METHOD We analysed data from the Austrian Stroke Unit registry concerning admissions from January 2003 to December 2013 and assessed the prevalence of PSP at the stroke unit. Patients with and without PSP were compared in univariate and multivariate models searching for factors associated with the occurrence of PSP at the SU. RESULTS Three thousand one hundred eleven patients (5.2%) of 59,558 analysed patients were diagnosed with PSP. While age and stroke severity were non-modifiable factors associated with PSP, modifiable risk factors included chronic alcohol consumption and atrial fibrillation. Patients who developed neurological, cardiac, and other infective complications showed a higher prevalence of PSP, an increased prevalence was also found in connection with the placement of nasogastric tubes or urinary catheters. Female sex, left hemispheric stroke, cryptogenic stroke pathogenesis and additionally, treatment with lipid lowering drugs were factors associated with a lower PSP prevalence. CONCLUSION Pneumonia in acute ischemic stroke is associated with a variety of modifiable and unmodifiable factors that allow to identify patients at high risk of developing PSP and to focus on early preventive measures at the SU. Further studies could use the results of this study to explore potential benefits of specific interventions targeted at these factors.
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Affiliation(s)
- Karl Matz
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria. .,Department of Neurology, University Clinic Tulln, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Krems, Austria.
| | - Leonhard Seyfang
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria
| | - Alexandra Dachenhausen
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria
| | - Yvonne Teuschl
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria
| | - Jaakko Tuomilehto
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria.,Department of Chronic Disease Prevention, National Institute for Health and Welfare, 00271, Helsinki, Finland.,Diabetes Research Group, King Abdulaziz University, 21589, Jeddah, Saudi Arabia
| | - Michael Brainin
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria.,Department of Neurology, University Clinic Tulln, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Krems, Austria
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25
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Increased expression of microRNA-21 in peripheral blood mediates the down-regulation of IFN-γ and increases the prevalence of stroke-associated infection. J Neurol Sci 2016; 366:235-239. [DOI: 10.1016/j.jns.2016.03.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/13/2016] [Accepted: 03/21/2016] [Indexed: 11/22/2022]
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26
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Statin Medication Use and Nosocomial Infection Risk in the Acute Phase of Stroke. J Stroke Cerebrovasc Dis 2016; 25:2360-7. [PMID: 27292907 DOI: 10.1016/j.jstrokecerebrovasdis.2016.05.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/21/2016] [Accepted: 05/23/2016] [Indexed: 11/22/2022] Open
Abstract
GOAL Statins have immunomodulatory and peripheral anti-inflammatory properties that are independent of their lipid-lowering action. Whether these properties reduce the risk for developing poststroke infection is debated in clinical literature. We estimated the risk for developing nosocomial poststroke infection based on statin exposure in patients aged 18 or older hospitalized for ischemic stroke. MATERIALS AND METHODS A consecutive sample of acute care hospital electronic medical records was retrospectively analyzed. Patients were assigned to the exposed cohort either when statin use preceded infection or statin medication was used, but no infection developed. The unexposed cohort included patients not on statins or initiating statins after infection developed. The association of statin exposure with infection was examined with conditional logistic regression adjusted for poststroke infection risk factors. Cochran-Mantel-Haenszel analyses examined the association of statin exposure and infection status within strata of binary predictor variables that increased infection risk. FINDINGS Up to 1612 records were analyzed: 1151 in the exposed cohort and 461 in the unexposed cohort. Infection developed in 20% of the statin-exposed patients and in 41% of the statin-unexposed patients (P < .001). Exposure to statins reduced odds for developing nosocomial infection by 58% over no exposure (adjusted odds ratio = .418, P < .001). Statins lowered the infection risk for both sexes, patients with a nasogastric tube, and patients with dysphagia (P < .05). Statins did not change infection risk for patients with endotracheal intubation. CONCLUSIONS In patients with ischemic stroke and without endotracheal intubation, statin medications were associated with reduced risk of nosocomial infections.
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27
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Hong KS, Lee JS. Statins in Acute Ischemic Stroke: A Systematic Review. J Stroke 2015; 17:282-301. [PMID: 26437994 PMCID: PMC4635713 DOI: 10.5853/jos.2015.17.3.282] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/02/2015] [Accepted: 04/04/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Statins have pleiotropic effects of potential neuroprotection. However, because of lack of large randomized clinical trials, current guidelines do not provide specific recommendations on statin initiation in acute ischemic stroke (AIS). The current study aims to systematically review the statin effect in AIS. METHODS From literature review, we identified articles exploring prestroke and immediate post-stroke statin effect on imaging surrogate markers, initial stroke severity, functional outcome, and short-term mortality in human AIS. We summarized descriptive overview. In addition, for subjects with available data from publications, we conducted meta-analysis to provide pooled estimates. RESULTS In total, we identified 70 relevant articles including 6 meta-analyses. Surrogate imaging marker studies suggested that statin might enhance collaterals and reperfusion. Our updated meta-analysis indicated that prestroke statin use was associated with milder initial stroke severity (odds ratio [OR] [95% confidence interval], 1.24 [1.05-1.48]; P=0.013), good functional outcome (1.50 [1.29-1.75]; P<0.001), and lower mortality (0.42 [0.21-0.82]; P=0.0108). In-hospital statin use was associated with good functional outcome (1.31 [1.12-1.53]; P=0.001), and lower mortality (0.41 [0.29-0.58]; P<0.001). In contrast, statin withdrawal was associated with poor functional outcome (1.83 [1.01-3.30]; P=0.045). In patients treated with thrombolysis, statin was associated with good functional outcome (1.44 [1.10-1.89]; P=0.001), despite an increased risk of symptomatic hemorrhagic transformation (1.63 [1.04-2.56]; P=0.035). CONCLUSIONS The current study findings support the use of statin in AIS. However, the findings were mostly driven by observational studies at risk of bias, and thereby large randomized clinical trials would provide confirmatory evidence.
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Affiliation(s)
- Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
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28
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Bruening T, Al-Khaled M. Stroke-Associated Pneumonia in Thrombolyzed Patients: Incidence and Outcome. J Stroke Cerebrovasc Dis 2015; 24:1724-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 11/22/2014] [Accepted: 03/15/2015] [Indexed: 11/27/2022] Open
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29
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The Effects of Statins on Infections after Stroke or Transient Ischemic Attack: A Meta-Analysis. PLoS One 2015; 10:e0130071. [PMID: 26158560 PMCID: PMC4497719 DOI: 10.1371/journal.pone.0130071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 05/16/2015] [Indexed: 01/21/2023] Open
Abstract
Background Previous studies have reported that statins can prevent infections, and these findings were ascribed to the anti-inflammatory and immunomodulatory properties of statins. However, the effects of statins on the risk of infection after stroke or transient ischemic attack (TIA) remain controversial. The aim of this study was to evaluate the relationship between statins and the risk of infection after stroke or TIA by means of a meta-analysis. Methodology and Findings Studies were found by searching major electronic databases using key terms and restricting the results to studies published in English language and human studies. Pooled odds ratio (OR) for the association between infection and statins were analyzed using Stata software. A total of five studies that included 8,791 stroke or TIA patients (3,269 patients in the statin use group and 5,522 in the placebo group) were eligible and abstracted. Pooled analysis demonstrated that statins did not significantly affect the incidence of infection after stroke or TIA compared with a placebo (OR 0.819, 95% CI 0.582–1.151, I2 = 64.2%, p= 0.025). Sensitivity analyses showed that the removal of any single study did not significantly affect the pooled OR. Cumulative meta-analysis showed that the incidence of infection did not vary by publication year. No statistical evidence of publication bias was found among the studies selected, based on the results of Egger’s (p = 1.000) and Begg’s (p = 0.762) tests. Conclusions This meta-analysis does not support the hypothesis that statins reduce the risk of infections in stroke or TIA patients.
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Kishore AK, Vail A, Chamorro A, Garau J, Hopkins SJ, Di Napoli M, Kalra L, Langhorne P, Montaner J, Roffe C, Rudd AG, Tyrrell PJ, van de Beek D, Woodhead M, Meisel A, Smith CJ. How Is Pneumonia Diagnosed in Clinical Stroke Research? Stroke 2015; 46:1202-9. [DOI: 10.1161/strokeaha.114.007843] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/06/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Diagnosis of pneumonia complicating stroke is challenging, and there are currently no consensus diagnostic criteria. As a first step in developing such consensus-based diagnostic criteria, we undertook a systematic review to identify the existing diagnostic approaches to pneumonia in recent clinical stroke research to establish the variation in diagnosis and terminology.
Methods—
Studies of ischemic stroke, intracerebral hemorrhage, or both, which reported occurrence of pneumonia from January 2009 to March 2014, were considered and independently screened for inclusion by 2 reviewers after multiple searches using electronic databases. The primary analysis was to identify existing diagnostic approaches for pneumonia. Secondary analyses explored potential reasons for any heterogeneity where standard criteria for pneumonia had been applied.
Results—
Sixty-four studies (56% ischemic stroke, 6% intracerebral hemorrhage, 38% both) of 639 953 patients were included. Six studies (9%) reported no information on the diagnostic approach, whereas 12 (19%) used unspecified clinician-reported diagnosis or initiation of antibiotics. The majority used objective diagnostic criteria: 20 studies (31%) used respiratory or other published standard criteria; 26 studies (41%) used previously unpublished ad hoc criteria. The overall occurrence of pneumonia was 14.3% (95% confidence interval 13.2%–15.4%;
I
2
=98.9%). Occurrence was highest in studies applying standard criteria (19.1%; 95% confidence interval 15.1%–23.4%;
I
2
=98.5%). The substantial heterogeneity observed was not explained by stratifying for other potential confounders.
Conclusions—
We found considerable variation in terminology and the diagnostic approach to pneumonia. Our review supports the need for consensus development of operational diagnostic criteria for pneumonia complicating stroke.
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Affiliation(s)
- Amit K. Kishore
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Andy Vail
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Angel Chamorro
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Javier Garau
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Stephen J. Hopkins
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Mario Di Napoli
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Lalit Kalra
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Peter Langhorne
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Joan Montaner
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Christine Roffe
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Anthony G. Rudd
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Pippa J. Tyrrell
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Diederik van de Beek
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Mark Woodhead
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Andreas Meisel
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Craig J. Smith
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
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Tian L, Yue X, Xi G, Wang Y, Li Z, Zhou Y, Fan X. Multiple intracranial arterial stenosis influences the long-term prognosis of symptomatic middle cerebral artery occlusion. BMC Neurol 2015; 15:68. [PMID: 25925171 PMCID: PMC4416303 DOI: 10.1186/s12883-015-0326-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/17/2015] [Indexed: 11/22/2022] Open
Abstract
Background Large intracranial occlusive vascular disease is a major contributor to the incidence of stroke worldwide, especially when it involves the middle cerebral artery (MCA). The data on the prognosis of symptomatic atherosclerotic MCA occlusions (MCAO) with concomitant intracranial arterial disease (MCAO-AIS) are limited. MCAO-AIS may reflect the extent of the atherosclerotic intracranial disease, we hypotheses that coexisting intracranial arterial disease influenced the prognosis of MCAO. Methods Patients having survived at least one month after the initial ischemic stroke who suffered from atherosclerotic occlusion of the MCA were enrolled. According to their concomitant atherosclerotic intracranial arterial disease, the patients were assigned to one of two groups: the MCAO or the MCAO-AIS. All of the patients’ cerebrovascular risk factors were recorded. Recurrent ischemic stroke and death were the end-point events during the follow-up. Results A total of 232 patients (mean age 57.68 ± 9.50 years; 69% male) were analyzed. The mean follow-up time was 17.65 months. The end-point events occurred in 35 (15.09%) patients, resulting in an annual rate of 10.26%. The presence of MCAO- AIS was an independent risk factor associated with the patient’s prognosis in the cohort (OR = 3.426, 95% CI 1.261 to 9.308; p = 0.016), as well as gender and diabetes mellitus. The MCAO-AIS were more likely to experience ipsilateral ischemic strokes, but the difference was not statistically significant. Conclusion Concomitant intracranial arterial disease may influence the prognosis of patients with atherosclerotic MCAO. The result warrants further research in larger sample population.
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Affiliation(s)
- Lili Tian
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China. .,Department of Neurology, The People's Hospital of Fuyang City, 63 Luci Road, Fuyang, 236010, Anhui Province, China.
| | - Xuanye Yue
- Department of Neurology, Department of Neurology and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, 300052, China.
| | - Gangming Xi
- Department of Neurology, Shanghai Clinical Center, Chinese Academy of Sciences/Shanghai Xuhui Central Hospital, 966 Middle Huaihai, Shanghai, 200030, China.
| | - Youmeng Wang
- Department of Neurology, The People's Hospital of Fuyang City, 63 Luci Road, Fuyang, 236010, Anhui Province, China.
| | - Zongyou Li
- Department of Neurology, The People's Hospital of Fuyang City, 63 Luci Road, Fuyang, 236010, Anhui Province, China.
| | - Ying Zhou
- Department of Neurology, The People's Hospital of Fuyang City, 63 Luci Road, Fuyang, 236010, Anhui Province, China.
| | - Xiaobing Fan
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China.
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