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Li Z, Pang M, Zhang J, Mao L, Wang X, Sun P. Effect of ventilation modalities on the early prognosis of patients with poststroke sleep apnea. Ann Clin Transl Neurol 2024; 11:355-367. [PMID: 38010089 PMCID: PMC10863924 DOI: 10.1002/acn3.51956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/09/2023] [Accepted: 11/11/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE Continuous positive airway pressure (CPAP) is the primary modality for treating sleep apnea after acute ischemic stroke (AIS). However, not all patients are well adherent to CPAP. Finding an alternative modality of ventilation to CPAP is essential. METHODS This prospective randomized clinical trial was conducted from 1 May 2022 to 8 January 2023 at the Department of Neurology, Wuhan Union Hospital. Participants diagnosed with sleep apnea after AIS were grouped according to block randomization principles into the usual care group (nasal cannula and facemask), nasal continuous positive airway pressure (nCPAP) group, and high-flow nasal cannula (HFNC) group. Rates of pulmonary infection and endotracheal intubation within 1 week of hospitalization and 28-day mortality (poststroke) were the primary outcomes (early prognosis). RESULTS In the trial, 178 patients (119 males [66.85%]; mean [SD] age, 61.04 [11.78] years) were eventually enrolled in the usual care group (n = 63), the nCPAP group (n = 55), and the HFNC group (n = 60). After ventilation, the nCPAP and HFNC groups were more effective than the usual care group in reducing the rate of pulmonary infection, endotracheal intubation, and improving neurological function and sleep apnea severity. However, there was no difference in 28-day mortality. Additionally, the improvement in prognosis was consistent between nCPAP and HFNC. In the comparison of comfort, the HFNC group was superior to nCPAP. INTERPRETATION nCPAP and HFNC reduced early pulmonary infection rates and endotracheal intubation rates. For patients with poor compliance with nCPAP, HFNC may be the best alternative.
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Affiliation(s)
- Zhuanyun Li
- Department of Emergency Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Ming Pang
- National Clinical Research Center for Geriatrics, West China HospitalSichuan UniversityChengduChina
| | - Jinnong Zhang
- Department of Emergency Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Ling Mao
- Department of Neurology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xiaorong Wang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Peng Sun
- Department of Emergency Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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2
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Bidkar PU, Kannabiran N, Chatterjee P. Clinical applications of ultrasound in neurosurgery and neurocritical care: A narrative review. Med J Armed Forces India 2024; 80:16-28. [PMID: 38239602 PMCID: PMC10793236 DOI: 10.1016/j.mjafi.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/17/2023] [Indexed: 01/22/2024] Open
Abstract
Ultrasonography (USG) has become an invaluable tool in the assessment of neurocritical patients in the operating theaters and critical care units. Due to its easy availability, reliability, safety, and repeatability, neuro-intensivists and neuro-anesthesiologists utilize USG to make a diagnosis, assess prognosis, and decide upon treatment. In neurocritical care units, USG has myriad indications for use, both systemic and neurologic. The neurological indications include the assessment of stroke, vasospasm, traumatic brain injury, brain death, acute brain damage, optic nerve sheath diameter, and pupillary reflexes to name a few. The systemic indications range from assessment of cardio-pulmonary function and intravascular volume status to detection of deep venous thromboses, vocal cord assessment in intubated patients, placement of central venous catheters, and percutaneous tracheostomy. In this narrative review, we iterate the clinical applications of USG in neuroanesthesia and neurocritical care, which we penned after searching relevant databases in PubMed, Medline, Ovid, and Google Scholar by using terms such as ‘applications of transcranial Doppler’, ‘optic nerve sheath diameter’, ‘USG applications in the critical care unit’, and so on. Our search database includes several research papers, neurocritical care books, review articles, and scientific databases. This article reviews various applications of USG in neuroanesthesia, neurosurgery, and neurocritical care.
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Affiliation(s)
- Prasanna Udupi Bidkar
- Professor & Unit Head (Neuroanesthesiology), Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | | | - Protiti Chatterjee
- Resident (Anesthesiology & Critical Care), Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
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3
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Non-association of stroke risk with intracranial hemodynamic steal in patients with symptomatic internal carotid artery occlusions. J Stroke Cerebrovasc Dis 2023; 32:106797. [PMID: 36527943 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/18/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Paradoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up. MATERIALS AND METHODS We prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death. RESULTS 36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89). CONCLUSIONS IHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.
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4
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Kargiotis O, Psychogios K, Safouris A, Spiliopoulos S, Karapanayiotides T, Bakola E, Mantatzis M, Dardiotis E, Ellul J, Giannopoulos S, Magoufis G, Tsivgoulis G. Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221136335. [PMID: 36437850 PMCID: PMC9685148 DOI: 10.1177/17562864221136335] [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: 05/04/2022] [Accepted: 10/16/2022] [Indexed: 07/27/2023] Open
Abstract
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
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Affiliation(s)
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
- Aktios Rehabilitation Center, Koropi,
Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional
Radiology Unit, ‘Attikon’ University General Hospital, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of
Medicine, Faculty of Health Sciences, AHEPA University General Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
| | - Michail Mantatzis
- Department of Radiology, Interventional
Neuroradiology Unit, AHEPA University General Hospital, Aristotle University
of Thessaloniki, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Medicine, University of Thessaly, Larissa,
Greece
| | - John Ellul
- Department of Neurology, University General
Hospital of Patras, Patras, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
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Bernard F, Barsan W, Diaz-Arrastia R, Merck LH, Yeatts S, Shutter LA. Brain Oxygen Optimization in Severe Traumatic Brain Injury (BOOST-3): a multicentre, randomised, blinded-endpoint, comparative effectiveness study of brain tissue oxygen and intracranial pressure monitoring versus intracranial pressure alone. BMJ Open 2022; 12:e060188. [PMID: 35273066 PMCID: PMC8915289 DOI: 10.1136/bmjopen-2021-060188] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/02/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Management of traumatic brain injury (TBI) includes invasive monitoring to prevent secondary brain injuries. Intracranial pressure (ICP) monitor is the main measurement used to that intent but cerebral hypoxia can occur despite normal ICP. This study will assess whether the addition of a brain tissue oxygenation (PbtO2) monitor prevents more secondary injuries that will translate into improved functional outcome. METHODS AND ANALYSIS Multicentre, randomised, blinded-endpoint comparative effectiveness study enrolling 1094 patients with severe TBI monitored with both ICP and PbtO2. Patients will be randomised to medical management guided by ICP alone (treating team blinded to PbtO2 values) or both ICP and PbtO2. Management is protocolised according to international guidelines in a tiered approach fashion to maintain ICP <22 mm Hg and PbtO2 >20 mm Hg. ICP and PbtO2 will be continuously recorded for a minimum of 5 days. The primary outcome measure is the Glasgow Outcome Scale-Extended performed at 180 (±30) days by a blinded central examiner. Favourable outcome is defined according to a sliding dichotomy where the definition of favourable outcome varies according to baseline severity. Severity will be defined according to the probability of poor outcome predicted by the IMPACT core model. A large battery of secondary outcomes including granular neuropsychological and quality of life measures will be performed. ETHICS AND DISSEMINATION This has been approved by Advarra Ethics Committee (Pro00030585). Results will be presented at scientific meetings and published in peer-reviewed publications. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03754114).
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Affiliation(s)
- Francis Bernard
- Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
- Department of Medicine, Université de Montreal, Montreal, Québec, Canada
| | - William Barsan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ramon Diaz-Arrastia
- Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lisa H Merck
- Emergency Medicine and Neurology, Neurocritical Care, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sharon Yeatts
- Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lori A Shutter
- Critical Care Medicine, Neurology, & Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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6
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Tsivgoulis G, Safouris A, Alexandrov AV. Ultrasonography. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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7
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Tanayapong P, Kuna ST. Sleep disordered breathing as a cause and consequence of stroke: A review of pathophysiological and clinical relationships. Sleep Med Rev 2021; 59:101499. [PMID: 34020180 DOI: 10.1016/j.smrv.2021.101499] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/12/2021] [Accepted: 04/25/2021] [Indexed: 12/22/2022]
Abstract
Stroke is the leading cause of death and disability globally. Sleep disordered breathing (SDB), a potentially modifiable risk factor of stroke, is highly prevalent in stroke survivors. Evidence supports a causal, bidirectional relationship between SDB and stroke. SDB may increase the risk of stroke occurrence and recurrence, and worsen stroke outcome. While SDB is associated with an increased incidence of hypertension and cardiac arrhythmias, both of which are traditional stroke risk factors, SDB is also an independent risk factor for stroke. A number of characteristics of SDB may increase stroke risk, including intermittent hypoxemia, sympathetic activation, changes in cerebral autoregulation, oxidative stress, systemic inflammation, hypercoagulability, and endothelial dysfunction. On the other hand, stroke may also cause new SDB or aggravate preexisting SDB. Continuous positive airway pressure treatment of SDB may have a beneficial role in reducing stroke risk and improving neurological outcome after stroke. The treatment should be considered as early as possible, particularly when SDB is present post-stroke. The goal of this review is to highlight the strong link between SDB and stroke and to raise awareness for practitioners to consider the possibility of SDB being present in all stroke survivors.
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Affiliation(s)
- Pongsakorn Tanayapong
- Division of Neurology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand; Neurology Center, Vibhavadi Hospital, Bangkok, Thailand.
| | - Samuel T Kuna
- Department of Medicine, Corporal Michael J. Crescenz VA, Medical Center, Philadelphia, PA, United States; Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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8
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Barlinn K, Jakubicek S, Siepmann T, Chernyshev OY, Pallesen LP, Wienecke M, Hermann W, Graehlert X, Alexandrov AW, Vosko M, Puetz V, Reichmann H, Bodechtel U, Mikulik R, Barlinn J, Alexandrov AV. Autotitrating Bilevel Positive Airway Pressure in Large Vessel Steno-Occlusive Stroke Patients With Suspected Sleep Apnea: A Multicenter Randomized Controlled Study. Front Neurol 2021; 12:667494. [PMID: 33927689 PMCID: PMC8076592 DOI: 10.3389/fneur.2021.667494] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/01/2021] [Indexed: 01/07/2023] Open
Abstract
Background: We hypothesized that autotitrating bilevel positive airway pressure (auto-BPAP) favorably affects short-term clinical outcomes in hyperacute ischemic stroke. Methods: In a multicenter, randomized, controlled trial patients with large vessel steno-occlusive stroke and clinically suspected sleep apnea were allocated to auto-BPAP or standard stroke care alone. Auto-BPAP was initiated within 24 h from stroke onset and performed over 48 h during diurnal and nocturnal sleep. Sleep apnea was assessed using cardiorespiratory polygraphy. Primary endpoint was early neurological improvement on National Institutes of Health Stroke Scale (NIHSS) score at 72 h. Safety and tolerability of BPAP, functional independence [modified Rankin Scale (mRS) 0–2], stroke recurrence, and mortality at 90 days were assessed. Results: Due to low recruitment, the trial was prematurely stopped after 24 patients had been randomized (auto-BPAP, n = 14; control, n = 10): median baseline NIHSS 13 (5.5–18), 88% large vessel occlusion, and 12% large vessel stenosis. Polygraphy confirmed sleep apnea in 64% of auto-BPAP and 88% of control patients (p = 0.34). Adherence to auto-BPAP was achieved by 9 of the 14 (64%) patients. Between auto-BPAP and control patients, no differences were observed in early neurological improvement (median NIHSS change: −2.0, IQR = 7 points vs. −0.5, IQR = 3 points), 90 days functional independence (21 vs. 30%, p = 0.67), stroke recurrence (0 vs. 20%, p = 0.16), and death (14 vs. 20%, p = 1.0). No safety concerns were identified. Conclusions: In this prematurely terminated trial, auto-BPAP was safe but did not show an effect on short-term clinical outcomes in selected ischemic stroke patients. Its tolerability, however, may be limited in hyperacute stroke care and needs to be improved before larger trials are conducted. Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT01812993.
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Affiliation(s)
- Kristian Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stanislava Jakubicek
- International Clinical Research Center and Neurology Department, St. Anne's University Hospital and Masaryk University, Brno, Czechia
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Oleg Y Chernyshev
- Department of Neurology and Sleep Medicine, Louisiana State University Health-Shreveport, Shreveport, LA, United States
| | - Lars-Peder Pallesen
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Miriam Wienecke
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Departments of Neurology and Internal Medicine I, Interdisciplinary Sleep Centre, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Wiebke Hermann
- Departments of Neurology and Internal Medicine I, Interdisciplinary Sleep Centre, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Neurology, German Center for Neurodegenerative Diseases (DZNE), Rostock, Germany
| | - Xina Graehlert
- Coordination Center for Clinical Studies, Technische Universität Dresden, Dresden, Germany
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Milan Vosko
- Department of Neurology, Kepler University Hospital Linz, Linz, Austria
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ulf Bodechtel
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St. Anne's University Hospital and Masaryk University, Brno, Czechia
| | - Jessica Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States
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Advani R, Sandset EC, Stjernstrøm E. Reversed Robin Hood syndrome visualized by CT perfusion. Radiol Case Rep 2021; 16:884-887. [PMID: 33552346 PMCID: PMC7859170 DOI: 10.1016/j.radcr.2021.01.047] [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: 11/07/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 11/28/2022] Open
Abstract
Reversed Robin Hood Syndrome (RRHS) was first described in 2007 as a cause of worsening neurological deficit in the setting of an acute ischemic event. RRHS is the shunting of cerebral blood flow to nonstenotic vascular territories due to impaired vasodilation bought on by hypercapnia. A 77 year old lady presented with acute onset left hemiparesis and an exacerbation of her underlying chronic obstructive pulmonary disease (COPD). CT angiography and perfusion visualized RRHS and appropriate treatment was initiated. Treatment strategies for RRHS differ considerably to those for acute ischemic stroke. Choosing the correct treatment strategy is decisive for good clinical outcome.
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Affiliation(s)
- Rajiv Advani
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
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10
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Boulos MI, Dharmakulaseelan L, Brown DL, Swartz RH. Trials in Sleep Apnea and Stroke: Learning From the Past to Direct Future Approaches. Stroke 2020; 52:366-372. [PMID: 33349009 DOI: 10.1161/strokeaha.120.031709] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Few randomized controlled trials have evaluated the effectiveness of continuous positive airway pressure (CPAP) in reducing recurrent vascular events and mortality in poststroke obstructive sleep apnea (OSA). To date, results have been mixed, most studies were underpowered and definitive conclusions are not available. Using lessons learned from prior negative trials in stroke, we reappraise prior randomized controlled trials that examined the use of CPAP in treating poststroke OSA and propose the following considerations: (1) Intervention-based changes, such as ensuring that patients are using CPAP for at least 4 hours per night (eg, through use of improvements in CPAP technology that make it easier for patients to use), as well as considering alternative treatment strategies for poststroke OSA; (2) Population-based changes (ie, including stroke patients with severe and symptomatic OSA and CPAP noncompliers); and (3) Changes to timing of intervention and follow-up (ie, early initiation of CPAP therapy within the first 48 hours of stroke and long-term follow-up calculated in accordance with sample size to ensure adequate power). Given the burden of vascular morbidity and mortality in stroke patients with OSA, there is a strong need to learn from past negative trials and explore innovative stroke prevention strategies to improve stroke-free survival.
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Affiliation(s)
- Mark I Boulos
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laavanya Dharmakulaseelan
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Devin L Brown
- Department of Neurology, University of Michigan, Ann Arbor (D.L.B.)
| | - Richard H Swartz
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
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11
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Kargiotis O, Psychogios K, Safouris A, Magoufis G, Palaiodimou L, Theodorou A, Bakola E, Stamboulis E, Krogias C, Tsivgoulis G. Transcranial Doppler Monitoring of Acute Reperfusion Therapies in Acute Ischemic Stroke Patients with Underlying Large Vessel Occlusions. ACTA ACUST UNITED AC 2020. [DOI: 10.31728/jnn.2020.00084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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12
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Jiang YJ, Wang ZM, Wang ZY, Wei CJ. Association between serum lipoprotein levels and neurological function in patients with acute ischemic stroke: A protocol of systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20258. [PMID: 32443365 PMCID: PMC7253775 DOI: 10.1097/md.0000000000020258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/14/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The target of this study is to summarize the association between the serum lipoprotein levels and neurological function in patients with acute ischemic stroke. METHODS A comprehensive search of Cochrane Library, PUBMED, EMBASE, Web of Science, and Chinese Biomedical Literature Database, China National Knowledge Infrastructure from inception to the February 29, 2020 without language and publication date restrictions. All searched studies will be selected by 2 authors independently against the eligibility criteria. Included studies will be critically appraised, and essential data will be extracted by 2 independent authors. If necessary, meta-analysis will be utilized to synthesize the outcome data from included articles. If it is not possible, a narrative synthesis will be undertaken. RESULTS This study will summarize the up-to-date evidence to investigate the association between serum lipoprotein levels and neurological function in patients with acute ischemic stroke. CONCLUSION Its results may present beneficial evidence and guidance for the clinical practice and further studies. STUDY REGISTRATION NUMBER INPLASY202040043.
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13
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Goyal N, Tsivgoulis G, Frei D, Turk A, Baxter B, Froehler MT, Mocco J, Ishfaq MF, Malhotra K, Chang JJ, Hoit D, Elijovich L, Loy D, Turner RD, Mascitelli J, Espaillat K, Alexandrov AV, Arthur AS. Comparative Safety and Efficacy of Modified TICI 2b and TICI 3 Reperfusion in Acute Ischemic Strokes Treated With Mechanical Thrombectomy. Neurosurgery 2020; 84:680-686. [PMID: 29618102 DOI: 10.1093/neuros/nyy097] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/06/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the current standard of care for acute ischemic stroke (AIS) patients with emergent large-vessel occlusions (ELVO). Successful reperfusion of ELVO is traditionally defined by modified Thrombolysis in Cerebral Infarction (mTICI) grades of 2b or 3. OBJECTIVE To evaluate the comparative safety and efficacy of mTICI 2b and mTICI 3 reperfusion in AIS patients treated with MT. METHODS Consecutive ELVO patients who underwent MT at 6 high-volume centers were included in this analysis. Standard safety (3-mo mortality, symptomatic intracranial hemorrhage [sICH]) and efficacy (absolute and relative reduction in NIHSS-scores during hospitalization, functional-improvement [shift analysis in mRS-scores], and functional-independence [mRS-scores of 0-2] at 3-mo) were compared between patients who had mTICI 2b and mTICI 3 reperfusion post MT. RESULTS A total of 416 ELVO patients achieved successful reperfusion with mTICI 2b (n = 216) and mTICI 3 (n = 200) following MT. The mTICI 3 group had significantly (P < .05) greater absolute (11 vs 9 points) and relative (77% vs 63%) reduction in NIHSS-scores during hospitalization, lower sICH (6% vs 12%), and higher 3-mo functional-independence (55% vs 44%) rates. Successful reperfusion with mTICI 3 was independently (P < .05) associated with greater absolute and relative reduction in NIHSS-scores during hospitalization as well as higher odds of 3-mo functional improvement (common odds ratios: 1.67; 95% confidence interval: 1.10-2.56) and functional independence (odds ratio: 2.08; 95% confidence interval: 1.22-3.53) in multivariable regression models adjusting for confounders. CONCLUSION Successful reperfusion with mTICI 3 was associated with greater neurological improvement during hospitalization and better 3-mo functional outcomes in comparison to mTICI 2b reperfusion.
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Affiliation(s)
- Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.,Second Department of Neurology, "Attikon University Hospital," School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Donald Frei
- Department of Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado
| | - Aquilla Turk
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Blaise Baxter
- Department of Interventional Neuroradiology, Erlanger Hospital, Chattanooga, Tennessee
| | | | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Muhammad Fawad Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Konark Malhotra
- Department of Neurology, West Virginia University Charleston Division, Charleston, West Virginia
| | - Jason J Chang
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.,Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee
| | - David Loy
- Department of Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado
| | - Raymond D Turner
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Justin Mascitelli
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | | | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee
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Hindman BJ, Dexter F. Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 2: Integrating and Applying Observational Reports and Randomized Clinical Trials. Anesth Analg 2019; 128:706-717. [PMID: 30883416 DOI: 10.1213/ane.0000000000004045] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The 2018 American Heart Association stroke care guidelines consider endovascular thrombectomy to be the standard of care for patients who have acute ischemic stroke in the anterior circulation when arterial puncture can be made: (1) within 6 h of symptom onset; or (2) within 6-24 h of symptom onset when specific eligibility criteria are satisfied. The aim of this 2-part review is to provide practical perspective on the clinical literature regarding anesthesia care of endovascular thrombectomy patients. In the preceding companion article (part 1), the rationale for rapid workflow and maintenance of blood pressure before reperfusion were reviewed. Also in part 1, the key patient and procedural factors determining endovascular thrombectomy effectiveness were identified. In this article (part 2), the observational literature regarding anesthesia for endovascular thrombectomy is summarized briefly, largely to identify its numerous biases, but also to develop hypotheses regarding sedation versus general anesthesia pertaining to workflow, hemodynamic management, and intra- and post-endovascular thrombectomy adverse events. These hypotheses underlie the conduct and outcome measures of 3 recent randomized clinical trials of sedation versus general anesthesia for endovascular thrombectomy. A meta-analysis of functional outcomes from these 3 trials show, when managed according to trial protocols, sedation and general anesthesia result in outcomes that are not significantly different. Details regarding anesthesia and hemodynamic management from these 3 trials are provided. This article concludes with a pragmatic approach to real-time anesthesia decision-making (sedation versus general anesthesia) and the goals and methods of acute phase anesthesia management of endovascular thrombectomy patients.
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Affiliation(s)
- Bradley J Hindman
- From the Department of Anesthesia, The University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
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15
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Lin SH, Branson C, Leung J, Park L, Doshi N, Auerbach SH. Oximetry as an Accurate Tool for Identifying Moderate to Severe Sleep Apnea in Patients With Acute Stroke. J Clin Sleep Med 2018; 14:2065-2073. [PMID: 30518446 DOI: 10.5664/jcsm.7538] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/16/2018] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVES Sleep-disordered breathing (SDB) is highly prevalent in patients with acute stroke. SDB is often underdiagnosed and associated with neurological deterioration and stroke recurrence. Polysomnography or home sleep apnea testing (HSAT) is typically used as the diagnostic modality; however, it may not be feasible to use regularly in patients with acute stroke. We investigated the predictive performance of pulse oximetry, a simpler alternative, to identify SDB. METHODS The records of 254 patients, who were admitted to Boston Medical Center for acute stroke and underwent HSAT, were retrospectively reviewed. Oxygen desaturation index (ODI) from pulse oximetry channel were compared to respiratory event index (REI) obtained from HSAT devices. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ODI were calculated, and different ODI cutoff values to predict SDB were proposed. RESULTS ODI had a strong correlation (r = .902) and agreement with REI. ODI was accurate in predicting SDB at different REI thresholds (REI ≥ 5, REI ≥ 15, and REI ≥ 30 events/h) with the area under the curve (AUC) of .965, .974, and .951, respectively. An ODI ≥ 5 events/h rules in the presence of SDB (specificity 91.7%, PPV 96.3%). An ODI ≥ 15 events/h rules in moderate to severe SDB (specificity 96.4%, PPV 95%) and an ODI < 5 events/h rules out moderate to severe SDB (sensitivity 100%, NPV 100%). CONCLUSIONS Nocturnal pulse oximetry has a high diagnostic accuracy in predicting moderate to severe SDB in patients with acute stroke. Oximetry can be a simple modality to rapidly recognize patients with more severe SDB and facilitate the referral to the confirmation sleep study.
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Affiliation(s)
- Shih Hao Lin
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - Chantale Branson
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - Jamie Leung
- Boston University School of Medicine, Boston, Massachusetts
| | - Lisa Park
- Boston University School of Medicine, Boston, Massachusetts
| | - Nirmita Doshi
- Boston University School of Medicine, Boston, Massachusetts
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Banik S, Fisher JA, McKetton L, Venkatraghavan L. Mapping intracerebral steal during a hypercapnic challenge. Can J Anaesth 2017; 64:1265-1266. [DOI: 10.1007/s12630-017-0940-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/06/2017] [Accepted: 07/13/2017] [Indexed: 11/24/2022] Open
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Arboix A, Obach V, Sánchez MJ, Massons J. Complementary examinations other than neuroimaging and neurosonology in acute stroke. World J Clin Cases 2017; 5:191-202. [PMID: 28685132 PMCID: PMC5480067 DOI: 10.12998/wjcc.v5.i6.191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/21/2017] [Accepted: 04/10/2017] [Indexed: 02/05/2023] Open
Abstract
The etiologic diagnosis of cerebrovascular diseases requires non-routine complementary examinations to be performed. Thus, in specific cases, after neuroimaging (computed tomography/magnetic resonance imaging cerebral scan sequences) and neurosonology (Doppler test of the supra-aortic trunks, transcranial echography and echocardiography), which academically allow us to classify the patients according to their etiologic stroke subtype, further examinations must be used to make a correct etiologic diagnostic. The present review aims to update knowledge about the usefulness of the different tests of blood and urine, plain chest radiography, X-ray of the spine, skull and abdomen, lumbar puncture, electroencephalography, evoked potentials, polysomnography, and pathologic examination after biopsy of the artery, skin, muscles, nerves, meninges, and brain, in the management of patients who have suffered an acute stroke.
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Tsivgoulis G, Alexandrov AV, Katsanos AH, Barlinn K, Mikulik R, Lambadiari V, Bonakis A, Alexandrov AW. Noninvasive Ventilatory Correction in Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Stroke 2017; 48:2285-2288. [PMID: 28596449 DOI: 10.1161/strokeaha.117.017661] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 04/08/2017] [Accepted: 05/02/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Even though current guidelines suggest that noninvasive ventilatory correction (NIVC) could be considered for acute ischemic stroke patients with obstructive sleep apnea, available evidence is conflicting, with no adequately powered randomized clinical trial being available to date. METHODS We conducted a systematic review and meta-analysis of all available literature data evaluating the effect of NIVC on neurological improvement (based on decrease in National Institutes of Health Stroke Scale score), vascular events (recurrent stroke, transient ischemic attack, myocardial infarction and unstable angina), and mortality during the follow-up period. RESULTS We identified 4 randomized clinical trials and 1 prospectively matched observational cohort, comprising a total of 389 patients (59.8% males, mean age: 64.4 years). The risk of both performance and detection bias was considered high in most of the included randomized clinical trials because of the lack of blinding in participants, personnel and/or outcome assessors. The mean decrease in National Institutes of Health Stroke Scale scores during the first (≤30) days of acute ischemic stroke was found to be greater in NIVC-treated patients in comparison to controls (standardized mean difference, 0.38; 95% confidence interval, 0.11-0.66; P=0.007). However, no significant differences were detected between NIVC-treated acute ischemic stroke patients and controls on both the risk of vascular events (risk ratio, 0.53; 95% confidence interval, 0.25-1.14; P=0.11) and mortality (risk ratio, 0.71; 95% confidence interval, 0.37-1.36; P=0.30). No evidence of heterogeneity (I2=0%; P for Cochran Q>0.50) or publication bias were detected in all analyses. CONCLUSIONS NIVC seems to be associated with greater short-term neurological improvement in acute ischemic stroke patients with obstructive sleep apnea. This finding deserves further investigation within the settings of an adequately powered, sham-control, randomized clinical trial.
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Affiliation(s)
- Georgios Tsivgoulis
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., A.V.A., A.W.A.); Second Department of Neurology (G.T., A.H.K., A.B.) and Second Department of Internal Medicine (V.L.),"Attikon" University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina, Greece (A.H.K.); Department of Neurology, Carl Gustav Carus Hospital Dresden, Germany (K.B.); and International Clinical Research Center, Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic (R.M.).
| | - Andrei V Alexandrov
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., A.V.A., A.W.A.); Second Department of Neurology (G.T., A.H.K., A.B.) and Second Department of Internal Medicine (V.L.),"Attikon" University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina, Greece (A.H.K.); Department of Neurology, Carl Gustav Carus Hospital Dresden, Germany (K.B.); and International Clinical Research Center, Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic (R.M.)
| | - Aristeidis H Katsanos
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., A.V.A., A.W.A.); Second Department of Neurology (G.T., A.H.K., A.B.) and Second Department of Internal Medicine (V.L.),"Attikon" University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina, Greece (A.H.K.); Department of Neurology, Carl Gustav Carus Hospital Dresden, Germany (K.B.); and International Clinical Research Center, Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic (R.M.)
| | - Kristian Barlinn
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., A.V.A., A.W.A.); Second Department of Neurology (G.T., A.H.K., A.B.) and Second Department of Internal Medicine (V.L.),"Attikon" University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina, Greece (A.H.K.); Department of Neurology, Carl Gustav Carus Hospital Dresden, Germany (K.B.); and International Clinical Research Center, Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic (R.M.)
| | - Robert Mikulik
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., A.V.A., A.W.A.); Second Department of Neurology (G.T., A.H.K., A.B.) and Second Department of Internal Medicine (V.L.),"Attikon" University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina, Greece (A.H.K.); Department of Neurology, Carl Gustav Carus Hospital Dresden, Germany (K.B.); and International Clinical Research Center, Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic (R.M.)
| | - Vaia Lambadiari
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., A.V.A., A.W.A.); Second Department of Neurology (G.T., A.H.K., A.B.) and Second Department of Internal Medicine (V.L.),"Attikon" University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina, Greece (A.H.K.); Department of Neurology, Carl Gustav Carus Hospital Dresden, Germany (K.B.); and International Clinical Research Center, Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic (R.M.)
| | - Anastasios Bonakis
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., A.V.A., A.W.A.); Second Department of Neurology (G.T., A.H.K., A.B.) and Second Department of Internal Medicine (V.L.),"Attikon" University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina, Greece (A.H.K.); Department of Neurology, Carl Gustav Carus Hospital Dresden, Germany (K.B.); and International Clinical Research Center, Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic (R.M.)
| | - Anne W Alexandrov
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., A.V.A., A.W.A.); Second Department of Neurology (G.T., A.H.K., A.B.) and Second Department of Internal Medicine (V.L.),"Attikon" University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina, Greece (A.H.K.); Department of Neurology, Carl Gustav Carus Hospital Dresden, Germany (K.B.); and International Clinical Research Center, Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic (R.M.)
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Kumar R, Suri JC, Manocha R. Study of association of severity of sleep disordered breathing and functional outcome in stroke patients. Sleep Med 2017; 34:50-56. [PMID: 28522098 DOI: 10.1016/j.sleep.2017.02.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 02/13/2017] [Accepted: 02/17/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Sleep disordered breathing (SDB) is a prevalent yet underrecognized condition that may have major adverse consequences for those affected by it. We performed a prospective observational study to seek a correlation of severity of SDB with the severity of stroke and its functional outcome. METHODS Patients with history of recent-onset stroke were recruited and underwent overnight polysomnography (PSG) after the acute phase of the stroke was over; for defining hypopneas, 3% and 4% desaturation limits were used, and the apnea-hypopnea index was respectively calculated as AHI3% and AHI4%. Stroke severity was graded using the Scandinavian Stroke Scale. Functional disability and neurological impairment was evaluated six weeks after the PSG using the Barthel Index (<80 = functional dependence; ≥80 = functional independence) and modified Rankins Scale (>2 = poor outcome; ≤2 = good outcome). RESULTS A total of 50 patients were enrolled, 30 (60%) with ischemic stroke and 20 (40%) with hemorrhagic strokes. Of the patients, 39 (78%) had an AHI4% of >5/h, 23 (46%) had an AHI4% of >15/h, and 9 (18%) had an AHI4% of >30/h. Multivariate analysis showed that body mass index (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.04-1.54, p = 0.019) and Scandinavian Stroke Scale score (stroke severity) (OR = 0.86; 95% CI = 0.76-0.96, p = 0.009) were significant risk factors for predicting SDB (AHI4% > 15) in patients of stroke. When we looked for factors predicting outcomes, only AHI4% (OR = 1.20; 95% CI 1.01-1.43, p value 0.041) was predictive of the functional dependence (based on Barthel Index) of the patient and AHI4% (OR = 1.14; 95% CI 1.03-1.25, p = 0.008) and body mass index (OR = 0.75; 95% CI 0.59-0.96, p = 0.024) were found to be predictive of poor outcome (based on modified Rankins Scale). We obtained similar results, regardless of the hypopnea definition used. CONCLUSION In conclusion, given the high frequency of SDB in stroke patients and its correlation with poor outcome, screening for obstructive sleep apnea in all stroke and transient ischemic attack patients may be warranted.
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Affiliation(s)
- Rohit Kumar
- Department of Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjang Hosptial, New Delhi, India.
| | - Rajesh Manocha
- Department of Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
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Tsivgoulis G, Katsanos AH, Kadlecová P, Czlonkowska A, Kobayashi A, Brozman M, Švigelj V, Csiba L, Fekete K, Kõrv J, Demarin V, Vilionskis A, Jatuzis D, Krespi Y, Liantinioti C, Giannopoulos S, Mikulik R. Intravenous thrombolysis for ischemic stroke in the golden hour: propensity-matched analysis from the SITS-EAST registry. J Neurol 2017; 264:912-920. [PMID: 28315960 DOI: 10.1007/s00415-017-8461-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/06/2017] [Accepted: 03/13/2017] [Indexed: 01/20/2023]
Abstract
As there are scarce data regarding the outcomes of acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) within 60 min from symptom onset ("golden hour"), we sought to compare outcomes between AIS patients treated within [GH(+)] and outside [GH(-)] the "golden hour" by analyzing propensity score matched data from the SITS-EAST registry. Clinical recovery (CR) at 2 and 24 h was defined as a reduction of ≥10 points on NIHSS-score or a total NIHSS-score of ≤3 at 2 and 24 h, respectively. A relative reduction in NIHSS-score of ≥40% at 2 h was considered predictive of complete recanalization (CREC). Symptomatic intracranial hemorrhage (sICH) was defined using SITS-MOST criteria. Favorable functional outcome (FFO) was defined as a mRS-score of 0-1 at 3 months. Out of 19,077 IVT-treated AIS patients, 71 GH(+) patients were matched to 6882 GH(-) patients, with no differences in baseline characteristics (p > 0.1). GH(+) had higher rates of CR at 2 (31.0 vs. 12.4%; p < 0.001) and 24 h (41 vs. 27%; p = 0.010), CREC at 2 h (39 vs. 21%; p < 0.001) and FFO (46.5 vs. 34.0%; p = 0.028) at 3 months. The rates of sICH and 3-month mortality did not differ (p > 0.2) between the two groups. GH(+) was associated with 2-h CR (OR: 5.34; 95% CI 2.53-11.03) and CREC (OR: 2.38; 95% CI 1.38-4.09), 24-h CR (OR: 1.88; 95% CI 1.08-3.26) and 3-month FFO (OR: 2.02; 95% CI 1.15-3.54) in multivariable logistic regression models adjusting for potential confounders. In conclusion, AIS treated with IVT within the GH seems to have substantially higher odds of early neurological recovery, CREC, 3-month FFO and functional improvement.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece. .,International Clinical Research Center and Neurology Department, St. Anne's Hospital, Brno, Czech Republic.
| | - Aristeidis H Katsanos
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece.,Department of Neurology, University of Ioannina, Ioannina, Greece
| | - Pavla Kadlecová
- International Clinical Research Center and Neurology Department, St. Anne's Hospital, Brno, Czech Republic
| | - Anna Czlonkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Adam Kobayashi
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Miroslav Brozman
- Neurology Department, University Hospital Nitra, Nitra, Slovakia
| | - Viktor Švigelj
- Department of Vascular Neurology and Neurological Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Laszlo Csiba
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Klara Fekete
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Vida Demarin
- Department of Neurology, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Aleksandras Vilionskis
- Department of Neurology and Neurosurgery, Vilnius University and Republican Vilnius University Hospital, Vilnius, Lithuania
| | - Dalius Jatuzis
- Department of Neurology and Neurosurgery, Center for Neurology, Vilnius University, Vilnius, Lithuania
| | - Yakup Krespi
- Neurology Department and Stroke Center, Memorial Şişli Hospital, Istanbul, Turkey
| | - Chrissoula Liantinioti
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece
| | | | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St. Anne's Hospital, Brno, Czech Republic.,Medical Faculty of Masaryk University, Brno, Czech Republic
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Abstract
PURPOSE OF REVIEW This article provides a synopsis of the immediate and delayed medical complications of stroke, with an emphasis on prevention and management of these complications. RECENT FINDINGS Meta-analysis of the trials for endovascular treatment of acute stroke shows no significant increase in hemorrhagic events. Rehabilitation guidelines published by the American Heart Association and American Stroke Association in 2016 aid in providing the best clinical practice for patients with stroke, from the time of their initial hospitalization to their return to the community. SUMMARY Medical complications from stroke are common and are associated with poor clinical outcomes, increased length of hospital stays and higher rates of readmission, increased cost of care, delayed time to rehabilitation, and increased mortality. Being cognizant of the common complications encountered, taking appropriate measures to prevent them, and knowing how to manage them when they do occur are essential to the continued care of patients with stroke.
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Goyal N, Tsivgoulis G, Frei D, Turk A, Baxter B, Froehler MT, Mocco J, Vachhani J, Hoit D, Elijovich L, Loy D, Turner RD, Mascitelli J, Espaillat K, Alexandrov AV, Alexandrov AW, Arthur AS. A multicenter study of the safety and effectiveness of mechanical thrombectomy for patients with acute ischemic stroke not meeting top-tier evidence criteria. J Neurointerv Surg 2017; 10:10-16. [PMID: 28143898 DOI: 10.1136/neurintsurg-2016-012905] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND While mechanical thrombectomy (MT) has become the standard of care for patients with acute ischemic stroke (AIS) with emergent large-vessel occlusions (ELVO), recently published guidelines appropriately award top-tier evidence to the same selective criteria that were employed in completed clinical trials. We sought to evaluate the safety and effectiveness of MT in patients with AIS with ELVO who do not meet top-tier evidence criteria (TTEC). METHODS We conducted an observational study on consecutive patients with AIS with ELVO who underwent MT at six high-volume endovascular centers. Standard safety outcomes (3-month mortality, symptomatic intracranial hemorrhage) and effectiveness outcomes (3-month functional independence: modified Rankin Scale scores of 0-2) were compared between patients meeting and failing TTEC. RESULTS The sample consisted of 349 (60%) controls fulfilling TTEC and 234 (40%) non-TTEC patients. Control patients meeting TTEC for MT tended to have higher functional independence rates at 3 months (47% vs 39%; p=0.055), while the rates of symptomatic intracerebral hemorrhage (sICH) were similar (9%) in both groups (p=0.983). In multivariable logistic regression models, adherence to TTEC for MT was not independently related to any safety outcome (sICH: OR 0.71, 95% CI 0.30 to 1.68, p=0.434; 3-month mortality: OR 1.27, 95% CI 0.69 to 2.33, p=0.448) or effectiveness outcome (3-month functional independence: OR 0.81, 95% CI 0.48 to 1.37, p=0.434; 3-month functional improvement: OR 0.73, 95% CI 0.48 to 1.11, p=0.138) after adjusting for potential confounders. CONCLUSIONS Approximately 40% of patients with AIS with ELVO offered MT do not fulfill TTEC for MT. Patients who did not meet TTEC had high rates of good clinical outcome and low complication rates.
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Affiliation(s)
- Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Second Department of Neurology, "Attikon University Hospital", School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,International Clinical Research Center, St. Anne's Hospital, Brno, Czech Republic
| | - Donald Frei
- Department of Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
| | - Aquilla Turk
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Blaise Baxter
- Department of Interventional Neuroradiology, Erlanger Hospital, Chattanooga, Tennessee, USA
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University, Nashville, Tennessee, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York, USA
| | - Jay Vachhani
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - David Loy
- Department of Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
| | - Raymond D Turner
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Justin Mascitelli
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York, USA
| | - Kiersten Espaillat
- Cerebrovascular Program, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Australian Catholic University, Sydney, New South Wales, Australia
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee, USA
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Abstract
Over the last few decades, the management of acute ischemic stroke has undergone significant advancements with the introduction of intravenous thrombolysis and more recently punctuated by the success of endovascular mechanical thrombectomy trials for large vessel occlusion. These advancements have transformed the practice of neurocritical care. In this review, we present a case-based discussion of common brain reperfusion techniques with an emphasis on complication recognition and management. The article encompasses recent evidence-based recommendations as well as some of our own institutional protocols.
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Kargiotis O, Siahos S, Safouris A, Feleskouras A, Magoufis G, Tsivgoulis G. Subclavian Steal Syndrome with or without Arterial Stenosis: A Review. J Neuroimaging 2016; 26:473-80. [DOI: 10.1111/jon.12371] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 05/07/2016] [Indexed: 12/13/2022] Open
Affiliation(s)
- Odysseas Kargiotis
- Department of Neurology; Olympion General Clinic; Volou & Meilichou, Kato Sichena 26443 Patra Greece
- Stroke Unit; Metropolitan Hospital; Ethnarchou Makariou 9 & Elefth. Venizelou 1 18547 Piraeus Greece
| | - Simos Siahos
- Department of Cardiology; Olympion General Clinic; Volou & Meilichou, Kato Sichena 26443 Patra Greece
| | - Apostolos Safouris
- Stroke Unit; Metropolitan Hospital; Ethnarchou Makariou 9 & Elefth. Venizelou 1 18547 Piraeus Greece
- Stroke Unit, Department of Neurology; Brugmann University Hospital; Place Van Gehuchten 4 1020 Bruxelles Belgium
| | - Agisilaos Feleskouras
- Dialysis Unit; Olympion General Clinic; Volou & Meilichou, Kato Sichena 26443 Patra Greece
| | - Georgios Magoufis
- Stroke Unit; Metropolitan Hospital; Ethnarchou Makariou 9 & Elefth. Venizelou 1 18547 Piraeus Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” Hospital, School of Medicine; University of Athens; Athens Greece
- Department of Neurology; The University of Tennessee Health Science Center; Memphis TN
- International Clinical Research Center, Department of Neurology; St. Anne's University Hospital in Brno; Brno Czech Republic
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Kamimura HAS, Wang S, Wu SY, Karakatsani ME, Acosta C, Carneiro AAO, Konofagou EE. Chirp- and random-based coded ultrasonic excitation for localized blood-brain barrier opening. Phys Med Biol 2016; 60:7695-712. [PMID: 26394091 DOI: 10.1088/0031-9155/60/19/7695] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Chirp- and random-based coded excitation methods have been proposed to reduce standing wave formation and improve focusing of transcranial ultrasound. However, no clear evidence has been shown to support the benefits of these ultrasonic excitation sequences in vivo. This study evaluates the chirp and periodic selection of random frequency (PSRF) coded-excitation methods for opening the blood-brain barrier (BBB) in mice. Three groups of mice (n = 15) were injected with polydisperse microbubbles and sonicated in the caudate putamen using the chirp/PSRF coded (bandwidth: 1.5–1.9 MHz, peak negative pressure: 0.52 MPa, duration: 30 s) or standard ultrasound (frequency: 1.5 MHz, pressure: 0.52 MPa, burst duration: 20 ms, duration: 5 min) sequences. T1-weighted contrast-enhanced MRI scans were performed to quantitatively analyze focused ultrasound induced BBB opening. The mean opening volumes evaluated from the MRI were mm3, mm3and mm3 for the chirp, random and regular sonications, respectively. The mean cavitation levels were V.s, V.s and V.s for the chirp, random and regular sonications, respectively. The chirp and PSRF coded pulsing sequences improved the BBB opening localization by inducing lower cavitation levels and smaller opening volumes compared to results of the regular sonication technique. Larger bandwidths were associated with more focused targeting but were limited by the frequency response of the transducer, the skull attenuation and the microbubbles optimal frequency range. The coded methods could therefore facilitate highly localized drug delivery as well as benefit other transcranial ultrasound techniques that use higher pressure levels and higher precision to induce the necessary bioeffects in a brain region while avoiding damage to the surrounding healthy tissue.
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Tsivgoulis G, Katsanos AH, Sharma VK, Krogias C, Mikulik R, Vadikolias K, Mijajlovic M, Safouris A, Zompola C, Faissner S, Weiss V, Giannopoulos S, Vasdekis S, Boviatsis E, Alexandrov AW, Voumvourakis K, Alexandrov AV. Statin pretreatment is associated with better outcomes in large artery atherosclerotic stroke. Neurology 2016; 86:1103-11. [PMID: 26911636 DOI: 10.1212/wnl.0000000000002493] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/16/2015] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Even though statin pretreatment is associated with better functional outcomes and lower risk of mortality in acute ischemic stroke, there are limited data evaluating this association in acute ischemic stroke due to large artery atherosclerosis (LAA), which carries the highest risk of early stroke recurrence. METHODS Consecutive patients with acute LAA were prospectively evaluated from 7 tertiary-care stroke centers during a 3-year period. Statin pretreatment, demographics, vascular risk factors, and admission and discharge stroke severity were recorded. The outcome events of interest were neurologic improvement during hospitalization (quantified as the relative decrease in NIH Stroke Scale score at discharge in comparison to hospital admission), favorable functional outcome (FFO) (defined as modified Rankin Scale score of 0-1), recurrent stroke, and death at 1 month. Statistical analyses were performed using univariable and multivariable Cox regression models adjusting for potential confounders. All analyses were repeated following propensity score matching. RESULTS Statin pretreatment was documented in 192 (37.2%) of 516 consecutive patients with LAA (mean age: 65 ± 13 years; 60.8% men; median NIH Stroke Scale score: 9 points, interquartile range: 5-18). Statin pretreatment was associated with greater neurologic improvement during hospitalization and higher rates of 30-day FFO in unmatched and matched (odds ratio for FFO: 2.44; 95% confidence interval [CI]: 1.07-5.53) analyses. It was also related to lower risk of 1-month mortality and stroke recurrence in unmatched and matched analyses (hazard ratio for recurrent stroke: 0.11, 95% CI: 0.02-0.46; hazard ratio for death: 0.24, 95% CI: 0.08-0.75). CONCLUSION Statin pretreatment in patients with acute LAA appears to be associated with better early outcomes regarding neurologic improvement, disability, survival, and stroke recurrence.
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Affiliation(s)
- Georgios Tsivgoulis
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia.
| | - Aristeidis H Katsanos
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Vijay K Sharma
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Christos Krogias
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Robert Mikulik
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Konstantinos Vadikolias
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Milija Mijajlovic
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Apostolos Safouris
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Christina Zompola
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Simon Faissner
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Viktor Weiss
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Sotirios Giannopoulos
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Spyros Vasdekis
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Efstathios Boviatsis
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Anne W Alexandrov
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Konstantinos Voumvourakis
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
| | - Andrei V Alexandrov
- From the Department of Neurology (G.T., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K., C.Z., K.Voumvourakis), Attikon University Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T., R.M., V.W.), St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (A.H.K., S.G.), University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece; Division of Neurology (V.K.S.), Yong Loo Lin School of Medicine, National University of Singapore; Department of Neurology (C.K., S.F.), St. Josef-Hospital, Ruhr University, Bochum, Germany; Neurology Department (R.M., V.W.), St. Anne's Hospital and Masaryk University, Brno, Czech Republic; Department of Neurology (K.Vadikolias), University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Neurology Clinic (M.M.), Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia; Stroke Unit (A.S.), Department of Neurology, Brugmann University Hospital, Brussels, Belgium; Departments of Vascular Surgery (S.V.) and Neurosurgery (E.B.), Attikon University Hospital, University of Athens, Greece; and Australian Catholic University (A.W.A.), Sydney, Australia
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Brunser AM, Mansilla E, Hoppe A, Olavarría V, Sujima E, Lavados PM. The Role of TCD in the Evaluation of Acute Stroke. J Neuroimaging 2016; 26:420-5. [DOI: 10.1111/jon.12334] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/23/2015] [Accepted: 12/25/2015] [Indexed: 11/26/2022] Open
Affiliation(s)
- Alejandro M. Brunser
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Eloy Mansilla
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Arnold Hoppe
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Verónica Olavarría
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Emi Sujima
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Pablo M. Lavados
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
- Department of Neurological Sciences, Faculty of Medicine; Universidad de Chile; Santiago Chile
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Ding Q, Whittemore R, Redeker N. Excessive Daytime Sleepiness in Stroke Survivors: An Integrative Review. Biol Res Nurs 2016; 18:420-31. [PMID: 26792913 DOI: 10.1177/1099800415625285] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Excessive daytime sleepiness (EDS) is a prevalent symptom among stroke survivors. This symptom is an independent risk factor for stroke and may reduce stroke survivors' quality of life, cognitive functioning, and daytime functional performance. The lack of a universally accepted definition of EDS makes it difficult to measure EDS and synthesize research. The purpose of this integrative review is to describe poststroke EDS, ascertain conceptual and operational definitions of EDS, identify factors that contribute to EDS in stroke survivors, and explore outcomes associated with EDS in stroke survivors. We searched the following databases: PubMed and MEDLINE (OvidSP 1946-April; Week 2, 2015), Embase (OvidSP 1974-March; Week 1, 2015), and PsycINFO (OvidSP 1967-April; Week 2, 2015). Our search yielded 340 articles, 27 of which met inclusion criteria. The literature reveals EDS to be a multidimensional construct that is operationalized with both subjective and objective measures. Choosing measures that can quantify both the objective and subjective components is useful for gaining a comprehensive understanding of EDS. The antecedents of EDS are stroke, sleep-disordered breathing, reversed Robin Hood syndrome, and depression. The outcomes associated with EDS in stroke patients are serious and negative. Via synthesis of this research, we propose a possible framework for poststroke EDS, which may be of use in clinical practice and in research to identify valid quantifying methods for EDS as well as to prevent harmful outcomes in stroke survivors.
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Affiliation(s)
- Qinglan Ding
- School of Nursing, Yale University, West Haven, CT, USA
| | | | - Nancy Redeker
- School of Nursing, Yale University, West Haven, CT, USA
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Haršány M, Tsivgoulis G, Alexandrov AV. Ultrasonography. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kepplinger J, Barlinn K, Boehme AK, Gerber J, Puetz V, Pallesen LP, Schrempf W, Dzialowski I, Albright KC, Alexandrov AV, Reichmann H, von Kummer R, Bodechtel U. Association of sleep apnea with clinically silent microvascular brain tissue changes in acute cerebral ischemia. J Neurol 2013; 261:343-9. [PMID: 24292644 DOI: 10.1007/s00415-013-7200-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/18/2013] [Accepted: 11/20/2013] [Indexed: 02/07/2023]
Abstract
The aim of this study was to determine the importance of sleep apnea in relation to clinically silent microvascular brain tissue changes in patients with acute cerebral ischemia. Patients with acute cerebral ischemia prospectively underwent nocturnal respiratory polygraphy within 5 days from symptom-onset. Sleep apnea was defined as apnea-hypopnea-index (AHI) ≥5/h. Experienced readers blinded to clinical and sleep-related data reviewed brain computed tomography and magnetic resonance imaging scans for leukoaraiosis and chronic lacunar infarctions. Ischemic lesions were considered clinically silent when patients did not recall associated stroke-like symptoms. Functional outcome was assessed with modified Rankin Scale at discharge, 6 and 12 months. Fifty-one of 56 (91 %) patients had sleep apnea of any degree. Patients with moderate-to-severe leukoaraiosis (Wahlund score ≥5) were found to have higher mean AHI than those with none or mild leukoaraiosis (34.4 vs. 12.8/h, p < 0.001). Moderate-to-severe sleep apnea (AHI ≥15/h) was found to be an independent predictor of moderate-to-severe leukoaraiosis (adjusted OR 6.03, 95 % CI 1.76-20.6, p = 0.0042) and of moderate-to-severe leukoaraiosis associated with clinically silent chronic lacunar infarctions (adjusted OR 10.5, 95 % CI 2.19-50.6, p = 0.003). The higher the Wahlund score and the AHI, the more likely unfavorable functional outcome resulted over time (p = 0.0373). In acute cerebral ischemia, sleep apnea is associated with clinically silent microvascular brain tissue changes and may negatively influence functional outcome. Routine sleep apnea screening and further investigation of possible long-term effects of non-invasive ventilatory treatment of sleep apnea appear warranted in this at-risk population.
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Affiliation(s)
- Jessica Kepplinger
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Fetscherstrasse 74, 01307, Dresden, Germany,
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Kepplinger J, Barlinn K, Kolieskova S, Shahripour RB, Pallesen LP, Schrempf W, Graehlert X, Schwanebeck U, Sisson A, Zerna C, Puetz V, Reichmann H, Albright KC, Alexandrov AW, Vosko M, Mikulik R, Bodechtel U, Alexandrov AV. Reversal of the neurological deficit in acute stroke with the signal of efficacy trial of auto-BPAP to limit damage from suspected sleep apnea (Reverse-STEAL): study protocol for a randomized controlled trial. Trials 2013; 14:252. [PMID: 23941576 PMCID: PMC3751147 DOI: 10.1186/1745-6215-14-252] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/07/2013] [Indexed: 01/08/2023] Open
Abstract
Background Although the negative impact of sleep apnea on the clinical course of acute ischemic stroke (AIS) is well known, data regarding non-invasive ventilation in acute patients are scarce. Several studies have shown its tolerability and safety, yet no controlled randomized sequential phase studies exist that aim to establish the efficacy of early non-invasive ventilation in AIS patients. Methods/design We decided to examine our hypothesis that early non-invasive ventilation with auto-titrating bilevel positive airway pressure (auto-BPAP) positively affects short-term clinical outcomes in AIS patients. We perform a multicenter, prospective, randomized, controlled, third rater- blinded, parallel-group trial. Patients with AIS with proximal arterial obstruction and clinically suspected sleep apnea will be randomized to standard stroke care alone or standard stroke care plus auto-BPAP. Auto-BPAP will be initiated within 24 hours of stroke onset and performed for a maximum of 48 hours during diurnal and nocturnal sleep. Patients will undergo unattended cardiorespiratory polygraphy between days three and five to assess sleep apnea. Our primary endpoint will be any early neurological improvement on the NIHSS at 72 hours from randomization. Safety, tolerability, short-term and three-months functional outcomes will be assessed as secondary endpoints by un-blinded and blinded observers respectively. Discussion We expect that this study will advance our understanding of how early treatment with non-invasive ventilation can counterbalance, or possibly reverse, the deleterious effects of sleep apnea in the acute phase of ischemic stroke. The study will provide preliminary data to power a subsequent phase III study. Trial registration Clinicaltrials.gov Identifier: NCT01812993
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Teo K, Choy DK, Lwin S, Ning C, Yeo TT, Shen L, Chong VF, Teoh HL, Seet RC, Chan BP, Sharma AK, Sharma VK. Cerebral Hyperperfusion Syndrome After Superficial Temporal Artery-middle Cerebral Artery Bypass for Severe Intracranial Steno-occlusive Disease: A Case Control Study. Neurosurgery 2013; 72:936-42; discussion 942-3. [DOI: 10.1227/neu.0b013e31828bb8b3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Intracranial stenoses carry increased risk for cerebral ischemia. We perform external carotid-internal carotid (EC-IC) artery bypass in our patients with severe stenosis of the intracranial internal carotid (ICA) or middle cerebral artery (MCA) with impaired cerebral vasodilatory reserve (CVR).
OBJECTIVE:
To evaluate cerebral hemodynamics and cerebral hyperperfusion syndrome (HPS) in patients who develop focal neurological deficits after EC-IC bypass surgery.
METHODS:
Patients with severe intracranial ICA or MCA stenosis and impaired CVR on transcranial Doppler (TCD) derived breath-holding index (BHI) were evaluated with acetazolamide-challenged technetium-99m hexamethylpropyleneamineoxime–single-photon emission computed tomography (SPECT). EC-IC bypass surgery was offered to patients with impaired CVR on SPECT. Close monitoring was performed in patients developing focal neurological deficits within 7 days of surgery.
RESULTS:
Of 112 patients with severe intracranial ICA/MCA stenosis, 77 (69%) showed impaired CVR and 46 (41%) underwent EC-IC bypass. Transient neurological deficits within 7 days of surgery developed in 8 (17%). HPS was confirmed by CT perfusion and/or SPECT in 7 cases. A strong correlation was observed between HPS and preoperative TCD-BHI values (0%, 6.3%, and 41% in patients with BHI 0.3-0.69, 0-0.3 and <0, respectively; P = .012). HPS patients showed more than a 50% increase in MCA flow velocity on TCD (compared with preoperative values) on the operated side (63.3% vs 3.3% on control side, P < .001). Meticulous control of blood pressure and hydration led to rapid and complete resolution of neurological deficits in all cases.
CONCLUSION:
Symptomatic cerebral HPS is common in the early postoperative period after EC-IC bypass surgery. Early diagnosis and appropriate management might prevent the complications of this syndrome.
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Affiliation(s)
- Kejia Teo
- Division of Neurosurgery, National University Hospital, Singapore
| | - David K.S. Choy
- Division of Neurosurgery, National University Hospital, Singapore
| | - Sein Lwin
- Division of Neurosurgery, National University Hospital, Singapore
| | - Chou Ning
- Division of Neurosurgery, National University Hospital, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, National University Hospital, Singapore
| | - Liang Shen
- Division of Neurology, National University Hospital, Singapore
| | - Vincent F. Chong
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Hock L. Teoh
- Division of Neurology, National University Hospital, Singapore
| | - Raymond C. Seet
- Division of Neurology, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Arvind K. Sharma
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Vijay K. Sharma
- Division of Neurology, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Kepplinger J, Barlinn K, Albright KC, Schrempf W, Boehme AK, Pallesen LP, Schwanebeck U, Graehlert X, Storch A, Reichmann H, Alexandrov AV, Bodechtel U. Early sleep apnea screening on a stroke unit is feasible in patients with acute cerebral ischemia. J Neurol 2012; 260:1343-50. [PMID: 23263538 DOI: 10.1007/s00415-012-6803-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 12/08/2012] [Accepted: 12/11/2012] [Indexed: 12/23/2022]
Abstract
Early screening for sleep apnea (SA) is rarely considered in patients with acute cerebral ischemia. We aimed to evaluate the feasibility of early SA screening on a stroke unit, its impact on post-discharge SA care and the relation of SA to clinical features. Patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA) prospectively underwent overnight cardiorespiratory polygraphy within 3 ± 2 days of symptom-onset. Feasibility was defined as analyzable polygraphy in 90 % of studied patients. We enrolled 61 patients (84 % AIS, 16 % TIA): mean age 66 ± 8 years, 44 % men, median NIHSS 1 (0-15), median ESS 5 (0-13). Analyzability was given in 56/61 (91.8 %; one-sided 95 % CI, lower-bound 86.0 %) patients indicating excellent feasibility of early SA screening with no significant differences in stroke severity (100 % in TIA, 91 % minor stroke, 83 % major stroke, p = 0.474). Ninety-one percent (51/56) had an apnea-hypopnea index ≥ 5/h (median: 20/h [0-79]); 32 % (18/56) mild, 30 % (17/56) moderate, and 29 % (16/56) severe SA. When comparing sleep-related ischemic stroke (SIS) and non-SIS patients, no differences were found regarding the presence (95 vs. 89 %, p = 0.49) or severity (e.g., severe SA: 32 vs. 27 %, p = 0.69) of SA. After 12 months, 27/38 (71 %) patients given specific recommendations completed in-laboratory sleep work-up and 7/27 (25 %) were prescribed for non-invasive ventilatory correction. In conclusion, early SA screening is feasible in patients with acute cerebral ischemia and may have a positive impact on post-discharge SA care. Given the high frequency and atypical presentation of SA, early screening for SA should be considered in all acute cerebral ischemia patients.
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Affiliation(s)
- Jessica Kepplinger
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Fetscherstrasse 74, 01307 Dresden, Germany.
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Intracerebral steal phenomenon: a potential mechanism for contralateral stroke after carotid artery stenting. Neurologist 2012; 18:128-9. [PMID: 22549351 DOI: 10.1097/nrl.0b013e318253f8b5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The "intracerebral steal phenomenon (ISP)" is a paradoxical vasodilatory response that reduces the cerebral blood flow to the impaired perfusion area. This phenomenon has been mainly reported in patients with moyamoya vessels with hyperventilation and with the administration of specific drugs such as acetazolamide. We report a case with contralateral infarction that can be explained by ISP after carotid stenting. This report indicates that ISP should be considered as a potential mechanism for contralateral infarction after carotid stent insertion, particularly in the case of contralateral vessel stenosis.
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Tsivgoulis G, Apostolidou N, Giannopoulos S, Sharma VK. Hemodynamic causes of deterioration in acute ischemic stroke. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.permed.2012.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Affiliation(s)
- David J. Durgan
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX (D.J.D., R.M.B.)
| | - Robert M. Bryan
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX (D.J.D., R.M.B.)
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX (R.M.B.)
- Department of Medicine (Cardiovascular Sciences), Baylor College of Medicine, Houston, TX (R.M.B.)
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Minnerup J, Ritter MA, Wersching H, Kemmling A, Okegwo A, Schmidt A, Schilling M, Ringelstein EB, Schäbitz WR, Young P, Dziewas R. Continuous Positive Airway Pressure Ventilation for Acute Ischemic Stroke. Stroke 2012; 43:1137-9. [DOI: 10.1161/strokeaha.111.637611] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Jens Minnerup
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - Martin Andreas Ritter
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - Heike Wersching
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - André Kemmling
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - Angelika Okegwo
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - Antje Schmidt
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - Matthias Schilling
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - E. Bernd Ringelstein
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - Wolf Rüdiger Schäbitz
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - Peter Young
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
| | - Rainer Dziewas
- From the Department of Neurology (J.M., M.A.R., A.O., A.S., M.S., E.B.R., P.Y., R.D.), the Institute of Epidemiology and Social Medicine (H.W.), and the Institute for Clinical Radiology (A.K.), University of Münster, Münster, Germany; and EVK Bielefeld (W.R.S.), Neurologie Bethel, Bielefeld, Germany
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Abstract
BACKGROUND AND PURPOSE Current ischemic stroke reperfusion therapy consists of intravenous thrombolysis given in eligible patients after review of a noncontrast CT scan and a time-based window of opportunity. Rapid clot lysis has a strong association with clinical improvement but remains incomplete in many patients. This review appraises novel adjunctive or alternative approaches to current reperfusion strategies being tested in all trial phases. Summary of Review- Alternative approaches to current reperfusion therapy can be separated into 4 main categories: (1) combinatory approaches with other drugs or devices; (2) novel systemic thrombolytic agents; (3) endovascular medical or mechanical reperfusion treatments; and (4) noninvasive or minimally invasive methods to augment cerebral blood flow and alleviate intracranial blood flow steal. CONCLUSIONS Reperfusion treatments must be provided as fast as possible in patients most likely to benefit. Patients who fail to rapidly reperfuse may benefit from other strategies that maintain collateral flow or protect tissue at risk.
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Affiliation(s)
- Andrew D Barreto
- Department of Neurology, Program, The University of Texas–Houston Medical School, Houston, TX, USA.
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Demographic, clinical, and radiologic predictors of neurologic deterioration in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis 2011; 22:205-10. [PMID: 21903418 DOI: 10.1016/j.jstrokecerebrovasdis.2011.07.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 07/18/2011] [Accepted: 07/23/2011] [Indexed: 11/19/2022] Open
Abstract
One-third of patients with acute ischemic stroke develop early neurologic worsening, which is associated with increased mortality and long-term functional disability. We investigated the predictive factors for neurologic deterioration in patients with acute ischemic stroke within 1 week of onset. We retrospectively investigated 643 patients who were admitted within 2 days of acute ischemic stroke between April 2007 and March 2010. Neurologic deterioration was defined as an increase of 4 points or more in the National Institutes of Health Stroke Scale (NIHSS) score within 1 week of admission. We retrieved data on demographic and clinical characteristics, medications, and stroke subtypes. Out of 537 patients, deterioration was noted in 64 patients (11.9%; deterioration group). Multivariate analysis identified history of myocardial infarction (P < .001), NIHSS score ≥8 at onset (P < .001), high leukocyte count (P = .035), low-density lipoprotein cholesterol ≥140 mg/dL (P = .002), and hemoglobin A1c ≥7% (P = .006) as significant factors associated with deterioration. Branch atheromatous disease was more frequent in the deterioration group, and >90% of patients with deterioration either were discharged to nursing home care or died. Multivariate analysis of magnetic resonance imaging findings identified internal carotid/middle cerebral artery occlusion (each P < .001), striate capsular infarction (P = .030), pontine infarction (P = .047), and lesion size of 15-30 mm (P = .011) as independent factors associated with deterioration. Stroke patients with a high low-density lipoprotein level, high hemoglobin A1c level on admission, a history of myocardial infarction, and high NIHSS score are at high risk for neurologic deterioration. Patients with multiple risk factors for deterioration can benefit most from intensive monitoring.
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Whole body shaking due to intracranial blood flow steal. J Neurol Sci 2011; 305:165-6. [DOI: 10.1016/j.jns.2011.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 12/16/2010] [Accepted: 01/25/2011] [Indexed: 11/20/2022]
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Barlinn K, Alexandrov AV. Sleep-disordered breathing and arterial blood flow steal represent linked therapeutic targets in cerebral ischaemia. Int J Stroke 2011; 6:40-1. [PMID: 21205239 DOI: 10.1111/j.1747-4949.2010.00551.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The pathogenic link between sleep-disordered breathing and early neurological deterioration in acute ischaemic stroke patients is now a subject of clinical investigations. Vasomotor reactivity and intracranial blood flow steal in response to changing vasodilatory stimuli like carbon dioxide play a pivotal role in clinical deterioration with reversed Robin Hood syndrome. A mechanical ventilatory correction in selected acute stroke patients might have a beneficial effect on sleep-disordered breathing and brain perfusion. This is a novel therapeutic target and the missing link in the pathogenesis of early neurological deterioration and stroke recurrence.
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Affiliation(s)
- Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany.
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Vasdekis SN, Tsivgoulis G, Athanasiadis D, Andrikopoulou A, Voumvourakis K, Lazaris AM, Stamboulis E. Cerebrovascular reacivity assessment in patients with carotid artery disease: a combined TCD and NIRS study. J Neuroimaging 2011; 22:261-5. [PMID: 21447029 DOI: 10.1111/j.1552-6569.2011.00595.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Transcranial Doppler (TCD) and near-infrared spectroscopy (NIRS) are two noninvasive diagnostic tools that have been shown to evaluate cerebral vasomotor reactivity by measuring changes in mean cerebral blood flow velocities (MCBFV) of proximal intracranial arteries and absolute brain-tissue oxygen-saturation (TOS) in microcirculation, respectively, during hemodynamic challenge. We evaluated the potential correlation between TCD and NIRS measurements of vasomotor reactivity (VMR) in patients with carotid artery disease (CARAD). METHODS Consecutive patients (n = 24) with CARAD underwent simultaneously TCD and NIRS examinations during voluntary breath-holding (BH). MCBFV and TOS values were recorded at baseline (BAS) and at the end of BH, while BH duration (DBH) was documented. VMR was quantified by means of TCD-BHI (Breath-holding Index: [MCBFV(BH) - MCBFV(BAS)]× 100/MCBFV(BAS)/DBH) and NIRS-BHI ([TOS(BH) - TOS(BAS)]× 100/ TOS(BAS)/DBH). RESULTS TCD-BHI correlated positively with NIRS-BHI in the affected side (r = .538, P = .007). A stronger correlation between TCD-BHI and NIRS-BHI was documented in the nonaffected side (r = .768, P< .001). After adjusting for demographic characteristics, stroke risk factors and symptomatic status NIRS-BHI was linearly and independently associated with TCD-BHI both in the affected (β:+ .813, P = .001) and unaffected (β:+ .823, P < .001) side. CONCLUSIONS Circulatory assessment of VMR in proximal cerebral vessels by TCD correlates positively to functional measurements of VMR in microcirculation by NIRS in CARAD patients.
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Affiliation(s)
- Spyros N Vasdekis
- Vascular Unit, Third Department of Surgery, School of Medicine, University of Athens, Athens, Greece
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Tsivgoulis G, Zhang Y, Alexandrov AW, Harrigan MR, Sisson A, Zhao L, Brethour M, Cava L, Balucani C, Barlinn K, Patterson DE, Giannopoulos S, DeWolfe J, Alexandrov AV. Safety and tolerability of early noninvasive ventilatory correction using bilevel positive airway pressure in acute ischemic stroke. Stroke 2011; 42:1030-4. [PMID: 21372308 DOI: 10.1161/strokeaha.110.600221] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Hypercapnia can induce intracranial blood-flow steal from ischemic brain tissues, and early initiation of noninvasive ventilator correction (NIVC) may improve cerebral hemodynamics in acute ischemic stroke. We sought to determine safety and tolerability of NIVC initiated on hospital admission without polysomnography study. SUBJECTS AND METHODS Consecutive acute ischemic stroke patients were evaluated for the presence of a proximal arterial occlusion, daytime sleepiness, or history of obstructive sleep apnea, and acceptable pulse oximetry readings while awake (96%-100% on 2 to 4 L supplemental oxygen delivered by nasal cannula). NIVC was started on hospital admission as standard of care when considered necessary by treating physicians. NIVC was initiated using bilevel positive airway pressure at 10 cmH(2)O inspiratory positive airway pressure and 5 cmH(2)O expiratory positive airway pressure in combination with 40% fraction of inspired oxygen. All potential adverse events were prospectively documented. RESULTS Among 356 acute ischemic stroke patients (median NIHSS score, 5; interquartile range, 2-13), 64 cases (18%) received NIVC (median NIHSS score, 12; interquartile range, 6-17). Baseline stroke severity was higher and proximal arterial occlusions were more frequent in NIVC patients compared to the rest (P<0.001). NIVC was not tolerated by 4 patients (7%). Adverse events in NIVC included vomiting (n=1), aspiration pneumonia (n=1), respiratory failure/intubation (n=1), hypotension requiring pressors (n=1), and facial skin breakdown (n=3). The in-hospital mortality rate was 13% in NIVC patients and 8% in the rest (P=0.195). Neurological improvement during hospitalization tended to be greater in the NIVC group (median NIHSS score decrease, 2 points; interquartile range, 0-4) compared to the rest (median NIHSS score decrease, 1; interquartile range, 0-2; P=0.078). CONCLUSIONS In acute ischemic stroke patients with proximal arterial occlusion and excessive sleepiness or obstructive sleep apnea, NIVC can be initiated early with good tolerability and a relatively small risk of serious complications.
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Affiliation(s)
- Georgios Tsivgoulis
- Comprehensive Stroke Center, University of Alabama at Birmingham Hospital, Birmingham, AL, USA
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Tsivgoulis G, Heliopoulos I. Metabolic syndrome and impaired vasomotor reactivity: causal relationship or chance association? Eur J Neurol 2010; 17:e108; author reply e109. [DOI: 10.1111/j.1468-1331.2010.03182.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Barlinn K, Balucani C, Palazzo P, Zhao L, Sisson A, Alexandrov AV. Noninvasive ventilatory correction as an adjunct to an experimental systemic reperfusion therapy in acute ischemic stroke. Stroke Res Treat 2010; 2010:108253. [PMID: 21052540 PMCID: PMC2968418 DOI: 10.4061/2010/108253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 10/02/2010] [Accepted: 10/11/2010] [Indexed: 11/20/2022] Open
Abstract
Background. Obstructive sleep apnea (OSA) is a common condition in patients with acute ischemic stroke and associated with early clinical deterioration and poor functional outcome. However, noninvasive ventilatory correction is hardly considered as a complementary treatment option during the treatment phase of acute ischemic stroke.
Summary of Case. A 55-year-old woman with an acute middle cerebral artery (MCA) occlusion received intravenous tissue plasminogen activator (tPA) and enrolled into a thrombolytic research study. During tPA infusion, she became drowsy, developed apnea episodes, desaturated and neurologically deteriorated without recanalization, re-occlusion or intracerebral hemorrhage. Urgent noninvasive ventilatory correction with biphasic positive airway pressure (BiPAP) reversed neurological fluctuation. Her MCA completely recanalized 24 hours later.
Conclusions. Noninvasive ventilatory correction should be considered more aggressively as a complementary treatment option in selected acute stroke patients. Early initiation of BiPAP can stabilize cerebral hemodynamics and may unmask the true potential of other therapies.
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Affiliation(s)
- Kristian Barlinn
- Comprehensive Stroke Center, Department of Neurology, University of Alabama at Birmingham, RWUH M226, 619 19th Street South, Birmingham, AL 35249-3280, USA
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