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Zhao P, Zhang G, Wang Y, Wei C, Wang Z, Zhai W, Shen Y, Shi L, Sun L. Peripheral immunity is associated with cognitive impairment after acute minor ischemic stroke and transient ischemic attack. Sci Rep 2024; 14:16201. [PMID: 39003356 PMCID: PMC11246473 DOI: 10.1038/s41598-024-67172-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 07/09/2024] [Indexed: 07/15/2024] Open
Abstract
Immunoinflammation is associated with the development of post-stroke cognitive impairment (PSCI), however, peripheral immunity has not been fully explored. We aimed to investigate the association between PSCI and peripheral immune indicators, including neutrophil, lymphocyte, and mononuclear percentages and counts; the systemic immune inflammation index; platelet-to-lymphocyte ratio; neutrophil-to-lymphocyte ratio (NLR); and lymphocyte-to-monocyte ratio. A total of 224 patients with acute minor ischemic stroke or transient ischemic attack with 6-12 months of follow-up were included. PSCI was defined as a Montreal Cognitive Assessment score < 22 during the follow-up period. We performed logistic regression, subgroup analyses based on age and sex, and further established predictive models. We found that increased innate immunity indicators (neutrophils, neutrophil percentage) increased the risk of PSCI, whereas increased adaptive immunity indicator (lymphocytes) were protective against PSCI, especially in patients aged 50-65 years. Neutrophil percentage and NLR improved the predictive efficacy of the models that included demographic, clinical, and imaging information, with the area under the curve increased from 0.765 to 0.804 and 0.803 (P = 0.042 and 0.049, respectively). We conducted a comprehensive analysis of peripheral immunity in PSCI, providing a novel perspective on the early detection, etiology, and treatment of PSCI.
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Affiliation(s)
- PanPan Zhao
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - GuiMei Zhang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - YongChun Wang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - ChunXiao Wei
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - ZiCheng Wang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - WeiJie Zhai
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - YanXin Shen
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - Lin Shi
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, Changchun, 130021, China
| | - Li Sun
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Xinmin Street 71#, Changchun, 130021, China.
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Hagberg G, Ihle-Hansen H, Abzhandadze T, Reinholdsson M, Hansen HI, Sunnerhagen KS. Prognostic value of acute National Institutes of Health Stroke Scale Items on disability: a registry study of first-ever stroke in the western part of Sweden. BMJ Open 2023; 13:e080007. [PMID: 38110379 DOI: 10.1136/bmjopen-2023-080007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVES We aimed to study how the individual items of the National Institutes of Health Stroke Scale (NIHSS) at admission predict functional independence 3 months post-stroke in patients with first-ever stroke. SETTING This registry-based study used data from two Swedish stroke registers (Riksstroke, the mandatory national quality register for stroke care in Sweden, and Väststroke, a local quality stroke register in Gothenburg). PARTICIPANTS This study included patients with first-ever acute stroke admitted from November 2014 to August 2018, with available NIHSS at admission and modified Rankin Scale (mRS) at 3-month follow-up. PRIMARY OUTCOME The primary outcome variable was mRS≤1 (defined as an excellent outcome) at 3-month follow-up. RESULTS We included 1471 patients, mean age was 72 (± 14.5) years, 48% were female, and 66% had mild strokes (NIHSS≤3). In adjusted binary logistic regression analysis, the NIHSS items impaired right motor arm and leg, and impairment in visual field, reduced the odds of an excellent outcome at 3 months ((OR 0.60 (95% CI 0.37 to 0.98), OR 0.60 (95% CI 0.37 to 0.97), and OR 0.65 (95% CI 0.45 to 0.94)). When exploring the effect size of associations between NIHSS items and mRS≤1 p, orientation, language and right leg motor had the largest yet small association. CONCLUSIONS Stroke patients with scores on the NIHSS items right motor symptoms or visual field at admission are less likely to have an excellent outcome at 3 months. Clinicians should consider the NIHSS items affected, not only the total NIHSS score, both in treatment guidance and prognostics.
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Affiliation(s)
- Guri Hagberg
- Oslo Stroke Unit, Neurological Department, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Neuroscience and Physiology, Section for Clinical Neuroscience and Rehabilitation, Gothenburg University, Goteborg, Sweden
| | - Haakon Ihle-Hansen
- Bærum Hospital- Vestre Viken Hospital Trust, Department of Medicine, Drammen, Norway
| | - Tamar Abzhandadze
- Institute of Neuroscience and Physiology, Section for Clinical Neuroscience and Rehabilitation, Gothenburg University, Goteborg, Sweden
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Malin Reinholdsson
- Institute of Neuroscience and Physiology, Section for Clinical Neuroscience and Rehabilitation, Gothenburg University, Goteborg, Sweden
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Hege Ihle Hansen
- Oslo Stroke Unit, Neurological Department, Oslo University Hospital, Ullevål, Oslo, Norway
- Bærum Hospital- Vestre Viken Hospital Trust, Department of Medicine, Drammen, Norway
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, Section for Clinical Neuroscience and Rehabilitation, Gothenburg University, Goteborg, Sweden
- Neurocare, Sahlgrenska University Hospital, Goteborg, Sweden
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Human-derived hair follicle stem cells and hydrogen sulfide on focal cerebral ischemia model: A comparative evaluation of radiologic, neurobehavioral and immunohistochemical results. Brain Res 2023; 1799:148170. [PMID: 36410427 DOI: 10.1016/j.brainres.2022.148170] [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: 08/20/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Abstract
The present study investigated the effects of intracerebral human-derived hair follicle stem cells (HFBSCs), whether alone or in combination with hydrogen sulfide (H2S) in a rat model of focal cerebral ischemia. The rats were randomly assigned into 4 groups (n = 10): Control (phosphate buffered saline (PBS)), Group A (at 24 h post-middle cerebral artery occlusion(MCAo), stereotaxic intracerebral, 1,0 × 106, total 10 μL HFBSCs), Group B (3-14 d post-MCAo, intraperitoneal (i.p.), 25 μM/kg/day H2S), Group AB (HFBSCs + H2S). Cranial magnetic resonance images were recorded on postoperative 1st and 28th days. Three dimensional analysis was performed to calculate the infarct volumes. Rotarod and cylinder tests were performed after MCAo and finally all rats were euthanized by cardiac perfusion at 28 days after MCAo for immunohistochemical analysis. The reduction in infarct volumes of rats receiving HFBSC was significant. The cranial infarct volume on the postoperative 28th day was significantly higher in the group in which H2S was administered alone compared to the HFBSC alone group. All animals showed steadily improved spontaneous locomotor activity from day 7 post-MCAo on rotarod test, from day 1 on cylinder test, but showed no significant differences at all times. In all groups, the grading scores of CD34, CD5, CD11b and GFAP immunohistochemical markers did not differ significantly. In conclusion, intracerebral HFBSC treatment after 24 h of ischemic stroke may be an effective way to reduce the cranial infarct volume, whereas H2S treatment alone or in combination with HFBSC may not be sufficient for ischemic brain injury.
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Farooqui A, Roman Casul YA, Jain V, Nagaraja N. Standard clinical and imaging-based small vessel disease parameters associated with mild stroke versus non-mild stroke. J Cent Nerv Syst Dis 2023; 15:11795735231151818. [PMID: 36659962 PMCID: PMC9843637 DOI: 10.1177/11795735231151818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/27/2022] [Indexed: 01/15/2023] Open
Abstract
Background Mild stroke has variable outcomes, and there is an ongoing debate regarding whether the administration of thrombolytics improves outcomes in this subgroup of stroke patients. Having a better understanding of the features of mild stroke may help identify patients who are at risk of poor outcomes. Objective The objective of this study is to evaluate the association of clinical and imaging-based small vessel disease features (white matter hyperintensities and cerebral microbleeds) with stroke severity and clinical outcomes in patients with mild stroke. Methods In this retrospective study, mild stroke was defined as a National Institute of Health stroke scale (NIHSS) score <5. Clinical, laboratory and imaging data were compared between patients with mild stroke versus non-mild stroke (NIHSS≥5). Multivariate logistic regression analysis was performed to identify predictors of mild stroke and poor discharge outcome. Results Among 296 patients included in the study, 131 patients (44%) had mild stroke. On multivariate analysis, patients with mild stroke were three times more likely to have sensory symptoms [odds ratio (OR) = 2.9; 95% confidence interval (CI) = (1.2-6.8)] and four times more likely to have stroke due to small vessel disease (OR = 3.7; 95%CI = 1.4-9.9). Among patients with mild stroke, higher age (OR = 1.1; 95%CI = 1.02-1.1), presence of cerebral microbleed (OR = 4.5; 95%CI = 1.5-13.8), vertigo (OR = 7.3; 95%CI = 1.2-45.1) and weakness (OR = 5.0; 95%CI = 1.2-20.3) as presenting symptoms were more likely to have poor discharge outcome. Conclusion Sensory symptoms and stroke due to small vessel disease are more common in mild stroke than non-mild stroke. Among patients with mild stroke, presence of cerebral microbleeds on imaging and symptoms of muscle weakness are associated with poor discharge outcome. Larger studies are needed to assess the impact of cerebral microbleed on mild stroke outcomes and risk stratify the benefit of thrombolytics in this group.
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Affiliation(s)
- Amreen Farooqui
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Yoram A Roman Casul
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Varun Jain
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA,Nandakumar Nagaraja, MD, MS, FAHA, Department of Neurology, Penn State Health Milton S. Hershey Medical Center, 30 Hope Drive Suite 2800 PO Box 859, Hershey, PA 17033, USA.
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Johnson N, Nisar T, Criswell A, McCane D, Lee J, Chiu D, Gadhia R. Long-Term Disability Outcomes for Patients With Ischemic Stroke Presenting With Visual Deficits. J Neuroophthalmol 2022; 42:518-523. [PMID: 36394966 DOI: 10.1097/wno.0000000000001624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ischemic strokes in both the anterior and posterior circulation can lead to visual deficits, which can affect functional ability. Thrombolytic therapies are often withheld to patients with visual deficits because of either being missed on initial evaluation or because of the misconception that their deficits are not as severe or as disabling. Alternatively, delays in patient arrival for emergent evaluation lead to missed opportunities for acute stroke treatment. This retrospective study aims to explore the differences in perceived long-term disability for patients with stroke who present with visual deficits vs those who do not as a manifestation of their acute stroke syndrome. In addition, we explore the differences in treatment effect with thrombolytics and further analyze if the region of ischemia causing the deficit leads to differences in disability outcomes. METHODS We conducted a retrospective analysis of patients with visual deficits as evidenced by an abnormal score on NIHSS categories related to vision (gaze palsy, visual fields, or extinction/inattention). Patients with Acute Ischemic Stroke were reviewed from the Houston Methodist Hospital Outcomes-based Prospective Endpoints in Stroke (HOPES) Registry from 2016-2021 for visual deficits. In total, 155 patient charts with visual deficits and 155 patient charts without a documented visual deficit were reviewed for ischemic stroke location (anterior vs posterior circulation), NIHSS scores, and thrombolytic therapies. The outcome variable was categorized using mRS, as mRS between 0 and 3 while mRS 4 to 6 was considered as poor functional outcome at 90 days. The independent variable was the vision group. A multivariable logistic regression model was constructed adjusting for demographics and comorbidities on the binary outcome. RESULTS Multivariable logistic model after adjusting for demographics and comorbidities showed that patients with acute ischemic stroke with vision defects were 4 times more likely to have poor functional outcomes at 90 days, with most of these patients (14% vs 6%; P < 0.05) suffering from severe disability compared with patients in the control group (i.e., patients with acute ischemic stroke without vision defects) (OR = 4.05; 95% CI [2.28-7.19]; P < 0.001). The application of thrombolytics and the location of ischemia (ACS vs PCS) did not result in a significant change in disability outcomes in patients with visual defects in this limited sample size. CONCLUSIONS The results of this study indicated that a large population of patients with ischemic stroke experience visual deficits and are, therefore, at an increased likelihood of worse functional outcome. This reveals the necessity for rehabilitation techniques that specifically target visual deficits to speed up the recovery process of these patients. Further studies with larger sample size are needed to assess whether the location of ischemic event and the application of thrombolytic treatments plays a role in the disability outcomes of these patients.
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Affiliation(s)
- Natalie Johnson
- Houston Methodist Neurological Institute (AC, DM, JL, DC, RG), Houston, Texas; Houston Methodist Research Institute (NJ), Houston, Texas; and Center for Outcomes Research (TN), Houston, Texas
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Sarraj A, Albers GW, Blasco J, Arenillas JF, Ribo M, Hassan AE, de la Ossa NP, Wu TYH, Cardona Portela P, Abraham MG, Chen M, Maali L, Kleinig TJ, Cordato D, Wallace AN, Schaafsma JD, Sangha N, Gibson DP, Blackburn SL, De Lera Alfonso M, Pujara D, Shaker F, McCullough-Hicks ME, Moreno Negrete JL, Renu A, Beharry J, Cappelen-Smith C, Rodríguez-Esparragoza L, Olivé-Gadea M, Requena M, Almaghrabi T, Mendes Pereira V, Sitton C, Martin-Schild S, Song S, Ma H, Churilov L, Mitchell PJ, Parsons MW, Furlan A, Grotta JC, Donnan GA, Davis SM, Campbell BCV. Thrombectomy versus Medical Management in Mild Strokes due to Large Vessel Occlusion: Exploratory Analysis from the EXTEND-IA Trials and a Pooled International Cohort. Ann Neurol 2022; 92:364-378. [PMID: 35599458 DOI: 10.1002/ana.26418] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate functional and safety outcomes for endovascular thrombectomy (EVT) versus medical management (MM) in patients with large vessel occlusion (LVO) and mild neurological deficits, stratified by perfusion imaging mismatch. METHODS The pooled cohort consisted of patients with National Institutes of Health Stroke Scale (NIHSS) < 6 and internal carotid artery (ICA), M1, or M2 occlusions from the Extending the Time for Thrombolysis in Emergecy Neurological Deficits - Intra-Arterial (EXTEND-IA) Trial, Tenecteplase vs Alteplase before Endovascular Thrombectomy in Ischemic Stroke (EXTEND-IA TNK) trials Part I/II and prospective data from 15 EVT centers from October 2010 to April 2020. RAPID software estimated ischemic core and mismatch. Patients receiving primary EVT (EVTpri ) were compared to those who received primary MM (MMpri ), including those who deteriorated and received rescue EVT, in overall and propensity score (PS)-matched cohorts. Patients were stratified by target mismatch (mismatch ratio ≥ 1.8 and mismatch volume ≥ 15ml). Primary outcome was functional independence (90-day modified Rankin Scale = 0-2). Secondary outcomes included safety (symptomatic intracerebral hemorrhage [sICH], neurological worsening, and mortality). RESULTS Of 540 patients, 286 (53%) received EVTpri and demonstrated larger critically hypoperfused tissue (Tmax > 6 seconds) volumes (median [IQR]: 64 [26-96] ml vs MMpri : 40 [14-76] ml, p < 0.001) and higher presentation NIHSS (median [IQR]: 4 [2-5] vs MMpri : 3 [2-4], p < 0.001). Functional independence was similar (EVTpri : 77.4% vs MMpri : 75.6%, adjusted odds ratio [aOR] = 1.29, 95% confidence interval [CI] = 0.82-2.03, p = 0.27). EVT had worse safety regarding sICH (EVTpri : 16.3% vs MMpri : 1.3%, p < 0.001) and neurological worsening (EVTpri : 19.6% vs MMpri : 6.7%, p < 0.001). In 414 subjects (76.7%) with target mismatch, EVT was associated with improved functional independence (EVTpri : 77.4% vs MMpri : 72.7%, aOR = 1.68, 95% CI = 1.01-2.81, p = 0.048), whereas there was a trend toward less favorable outcomes with primary EVT (EVTpri : 77.4% vs MMpri : 83.3%, aOR = 0.39, 95% CI = 0.12-1.34, p = 0.13) without target mismatch (pinteraction = 0.06). Similar findings were observed in a propensity score-matched subpopulation. INTERPRETATION Overall, EVT was not associated with improved clinical outcomes in mild strokes due to LVO, and sICH was increased. However, in patients with target mismatch profile, EVT was associated with increased functional independence. Perfusion imaging may be helpful to select mild stroke patients for EVT. ANN NEUROL 2022;92:364-378.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA
| | | | - Jordi Blasco
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Juan F Arenillas
- Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center, Harlingen, TX, USA
| | | | - Teddy Yuan-Hao Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Michael G Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Michael Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Laith Maali
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis Cordato
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia
| | | | - Joanna D Schaafsma
- Neurology, Department of Internal Medicine, Toronto Western Hospital-University Health Network, Toronto, ON, Canada
| | - Navdeep Sangha
- Department of Neurology, Kaiser Permanente, Los Angeles, CA, USA
| | - Daniel P Gibson
- Department of Neurosurgery, Ascension Wisconsin, Milwaukee, WI, USA
| | - Spiros L Blackburn
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, TX, USA
| | | | - Deep Pujara
- Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA
| | - Faris Shaker
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, TX, USA
| | | | | | - Arturo Renu
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - James Beharry
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Cecilia Cappelen-Smith
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia
| | | | - Marta Olivé-Gadea
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Tareq Almaghrabi
- Department of Internal Medicine, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
| | | | - Clark Sitton
- Department of Diagnostic and Interventional Radiology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Sheryl Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, LA, USA
| | - Sarah Song
- Department of Neurology, Rush University Medical Center, Chicago, IL, USA
| | - Henry Ma
- Department of Neurology, Monash University, Melbourne, Vic., Australia
| | - Leonid Churilov
- Department of Biostatistics, University of Melbourne, Parkville, Vic., Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, Parkville, Vic., Australia
| | - Mark W Parsons
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia
| | - Anthony Furlan
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA
| | - James C Grotta
- Department of Clinical Innovation and Research, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
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Su C, Yang X, Wei S, Zhao R. Periventricular white matter hyperintensities are associated with gait and balance in patients with minor stroke. Front Neurol 2022; 13:941668. [PMID: 35937058 PMCID: PMC9355320 DOI: 10.3389/fneur.2022.941668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveCerebral small vessel disease (CSVD) is associated with gait and balance deficits in older adults. However, the effect of CSVD-related brain injury on post-stroke mobility is unknown. This study aimed to investigate the association of CSVD with gait and balance impairment after a minor stroke.MethodsA total of 273 patients with a minor stroke (NIHSS ≤ 5 points) who were hospitalized at the Affiliated Hospital of Qingdao University were enrolled. The manifestations of white matter hyperintensities (WMH), lacunes, enlarged perivascular spaces (EPVS), and cerebral microbleeds (CMB) were statistically analyzed according to magnetic resonance imaging results, and the total burden score of CSVD was calculated. Gait function was assessed by a 6-m walking speed test, and balance function was assessed by the timed-up-and-go (TUG) test. Linear regression analysis was applied to determine the association after adjusting for key variables.ResultsThe correlation results showed that in patients with minor stroke, age, sex, smoking history, and the infarct site were associated with gait speed, and age and the infarct site were associated with the TUG test. In the univariate linear regression model, periventricular white matter hyperintensities (PVWMH), deep white matter hyperintensities (DWMH), and the total burden of CSVD were correlated with gait speed, while only PVWMH correlated with the TUG test. After adjusting for confounders, only PVWMH were independent predictors of gait speed (β = −0.089, p < 0.05) and the TUG test (β = 0.517, p < 0.05).ConclusionsOur study confirmed that CSVD is associated with gait and balance disorders after a minor stroke. PVWMH are independent predictors of gait and balance disorders in patients with minor stroke. These findings should be confirmed in larger prospective studies.
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Heldner MR, Chalfine C, Houot M, Umarova RM, Rosner J, Lippert J, Gallucci L, Leger A, Baronnet F, Samson Y, Rosso C. Cognitive Status Predicts Return to Functional Independence After Minor Stroke: A Decision Tree Analysis. Front Neurol 2022; 13:833020. [PMID: 35250835 PMCID: PMC8891604 DOI: 10.3389/fneur.2022.833020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
About two-thirds of patients with minor strokes are discharged home. However, these patients may have difficulties returning to their usual living activities. To investigate the factors associated with successful home discharge, our aim was to provide a decision tree (based on clinical data) that could identify if a patient discharged home could return to pre-stroke activities and to perform an external validation of this decision tree on an independent cohort. Two cohorts of patients with minor strokes gathered from stroke registries at the Hôpital Pitié-Salpêtrière and University Hospital Bern were included in this study (n = 105 for the construction cohort coming from France; n = 100 for the second cohort coming from Switzerland). The decision tree was built using the classification and regression tree (CART) analysis on the construction cohort. It was then applied to the validation cohort. Accuracy, sensitivity, specificity, false positive, and false-negative rates were reported for both cohorts. In the construction cohort, 60 patients (57%) returned to their usual, pre-stroke level of independence. The CART analysis produced a decision tree with the Montreal Cognitive Assessment (MoCA) as the first decision point, followed by discharge NIHSS score or age, and then by the occupational status. The overall prediction accuracy to the favorable outcome was 80% in the construction cohort and reached 72% accuracy in the validation cohort. This decision tree highlighted the role of cognitive function as a crucial factor for patients to return to their usual activities after a minor stroke. The algorithm may help clinicians to tailor planning of patients' discharge.
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Affiliation(s)
- Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Caroline Chalfine
- Assistance Publique – Hôpitaux de Paris (APHP) Service de Soins de Suite et Réadaptation, Hôpital Pitié-Salpêtrière, Paris, France
| | - Marion Houot
- Assistance Publique – Hôpitaux de Paris (APHP) Centre d'Investigations Cliniques de Neurosciences, Hôpital Pitié-Salpêtrière, Paris, France
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
| | - Roza M. Umarova
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Jan Rosner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Julian Lippert
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Laura Gallucci
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Anne Leger
- STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Flore Baronnet
- STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yves Samson
- STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Charlotte Rosso
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- *Correspondence: Charlotte Rosso
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Adams HP. Clinical Scales to Assess Patients With Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Edlow JA, Hoffmann B. Managing Patients With Acute Visual Loss. Ann Emerg Med 2021; 79:474-484. [PMID: 34922777 DOI: 10.1016/j.annemergmed.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Jonathan A Edlow
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Beatrice Hoffmann
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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11
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Factors Associated with Pre-Hospital Delay and Intravenous Thrombolysis in China. J Stroke Cerebrovasc Dis 2020; 29:104897. [PMID: 32430238 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104897] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/18/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pre-hospital delay was a critical factor affecting stroke patients receiving intravenous thrombolytic therapy. The aim of this study was to explore the factors associated with pre-hospital delay and thrombolysis in China. METHODS Patient data were obtained from emergency department (ED), and the factors of patient pre-hospital delay were recorded through a well-designed form. RESULTS A total of 630 patients were eventually included in the study. 317 patients were admitted to the ED during the thrombolysis time window, and only 105 patients received intravenous thrombolytic therapy. In the univariate analysis, transportation (OR: 0.15; 95% CI: 0.44 - 0.518; p = 0.001), atrial fibrillation (OR: 0.555; 95% CI: 0.372-0.828; p = 0.004) and response of symptoms (OR: 0.002; 95% CI: 0.000-0.013; p = 0.000) were associated with early arrival. Speech disturbances (OR: 2.095; 95% CI: 1.294-3.391; p = 0.002), smoking (OR: 2.563; 95% CI: 1.527-4.304; p = 0.000), alcohol consumption (OR: 2.155; 95% CI: 1.159-4.005; p = 0.014) and referral presentation (OR: 2.837; 95% CI: 1.584-5.082; p = 0.000) were associated with thrombolysis. In the logistic regression analysis, direct visiting to the hospital after onset and rushing to emergency after onset were independent predictor of early arrival of AIS and intravenous thrombolytic. CONCLUSIONS The pre-hospital delay of acute ischemic stroke in China was still serious. Strengthening the ability to identify stroke-related symptoms and establishing a mutual referral medical support service model between lower and upper hospitals may effectively shorten the pre-hospital delay of stroke patients.
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Zhang X, Wang L, Han Z, Dong J, Pang D, Fu Y, Li L. KLF4 alleviates cerebral vascular injury by ameliorating vascular endothelial inflammation and regulating tight junction protein expression following ischemic stroke. J Neuroinflammation 2020; 17:107. [PMID: 32264912 PMCID: PMC7140364 DOI: 10.1186/s12974-020-01780-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 03/18/2020] [Indexed: 12/22/2022] Open
Abstract
Background Although inflammatory cell adhesion molecules (CAMs) and anti-inflammation factor Kruppel-like transcription factor (KLF) 4 have all been reported to be induced after cerebral ischemic stroke (CIS), the close temporal and spatial relationship between expressions of CAMs and KLF4 following CIS and whether and how CAMs and KLF-4 contribute to the development of CIS-induced vascular injury are still unclear. Methods Here, we first examined the correlation between serum levels of CAMs/KLF4 and infarct volume in acute CIS patients. Then, we determined the relationship between CAMs and KLF4 in mice after focal cerebral ischemia. Finally, we investigated the mechanism of KLF4 in protecting against oxygen-glucose deprivation-induced brain endothelial cell injury. Results Our results demonstrated that patients with moderate to severe CIS had higher serum levels of three CAMs including E-selectin, inter-cellular adhesion molecule 1 (ICAM-1), and vascular cell adhesion molecule 1 (VCAM-1) but lower levels of KLF4 at 48 h after an acute event as compared to patients with minor CIS. The expression levels of three CAMs as well as KLF4 all correlated well with the infarct volume in all the CIS subjects at that time. Although the expressions of three CAMs and KLF4 were all induced in the ischemic hemisphere following focal cerebral ischemia, the peak timing and distribution patterns of their expression were different: the induction of KLF4 lagged behind that of the CAMs in the ischemic penumbra; furthermore, the dual immunofluorescent studies displayed that high expression of KLF4 was always associated with relatively less cerebral vascular endothelial inflammation response in the ischemic hemisphere and vice versa. Mechanistic analyses revealed that KLF4 alleviated CIS-induced cerebral vascular injury by regulating endothelial expressions of CAMs, nuclear factor-kB, and tight junction proteins. Conclusions These data indicate that KLF4 confers vascular protection against cerebral ischemic injury, suggesting that circulating CAMs and KLF4 might be used as potential biomarkers for predicting the prognosis of acute ischemic stroke and also providing a new proof of concept and potential targets for future prevention and treatment of CIS.
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Affiliation(s)
- Xinyu Zhang
- Department of Neurology, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Pudong New Area, Shanghai, 200135, People's Republic of China.,The Graduate School, Ningxia Medical University, Yinchuan, Ningxia, 750004, People's Republic of China
| | - Lu Wang
- Department of Neurology, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Pudong New Area, Shanghai, 200135, People's Republic of China
| | - Zhenxiang Han
- Department of Neurology and Rehabilitation, Seventh People's Hospital of Shanghai University of TCM, Shanghai, 200137, People's Republic of China
| | - Jing Dong
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, Shanghai, 200135, People's Republic of China
| | - Defang Pang
- Department of Special Outpatient Service, Gongli Hospital, The Second Military Medical University, Shanghai, 200135, People's Republic of China
| | - Yuan Fu
- Department of Neurology, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, 150001, People's Republic of China.
| | - Longxuan Li
- Department of Neurology, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Pudong New Area, Shanghai, 200135, People's Republic of China.
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Cucchiara B, George DK, Kasner SE, Knutsson M, Denison H, Ladenvall P, Amarenco P, Johnston SC. Disability after minor stroke and TIA. Neurology 2019; 93:e708-e716. [DOI: 10.1212/wnl.0000000000007936] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 03/21/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo examine factors associated with disability following TIA and minor stroke, including poststroke complications such as stroke recurrence, major bleeding, and other adverse medical events.MethodsThe SOCRATES trial randomized patients with TIA/minor stroke (NIH Stroke Scale [NIHSS] score ≤5) within 24 hours of onset. We performed a post hoc analysis of factors associated with disability (modified Rankin Scale [mRS] score >1). TIA and minor stroke were analyzed separately. Patients with premorbid mRS >0 were excluded.ResultsAt 90 days, 687/3,663 (19%) patients with stroke were disabled; for TIA, 122/2,384 (5%) were disabled. In multivariate analyses, age, diabetes, and NIHSS were associated with disability in the stroke cohort, and age with disability in the TIA cohort. Postrandomization events (recurrent stroke, myocardial infarction, major bleeding, serious adverse events) were strongly associated with disability in both cohorts (stroke cohort: odds ratio [OR] 5.6, 95% confidence interval [CI] 4.5–6.9; TIA cohort: OR 14.8, 95% CI 9.9–22.0). Of the TIA patients who ended up disabled, 65% experienced a postrandomization event; for stroke patients who ended up disabled, 39% had a postrandomization event. Disability increased linearly with NIHSS score (p < 0.0001) and was greater in those with limb weakness (p < 0.0001).ConclusionsAfter TIA and minor stroke, subsequent stroke and medical complications are strongly associated with disability. In addition, even within a low range of baseline scores, the NIHSS is a powerful predictor of disability in minor stroke patients, with items scoring limb weakness particularly associated with subsequent disability.
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Sand KM, Naess H, Thomassen L, Hoff JM. Visual field defect after ischemic stroke-impact on mortality. Acta Neurol Scand 2018; 137:293-298. [PMID: 29148038 DOI: 10.1111/ane.12870] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We aimed to investigate the impact of visual field defects (VFD) on mortality in ischemic stroke patients. MATERIALS AND METHODS All patients with acute infarction and a clinically detected VFD from February 2006 to December 2013 in the NORSTROKE Registry (n = 506) were included and compared with ischemic stroke patients with normal visual fields (n = 2041). A record of patients who had died per ultimo April 2015 was obtained from the central registry at Haukeland University Hospital. RESULTS Patients with VFD were significantly older (75.0 vs 69.8, P < .001) than patients with normal visual fields. The majority of patients with VFD was male, had higher cardiovascular morbidity prestroke, and were more likely to have shorter median time from symptom onset to admission (1.7 hours vs 2.7 hours, P < .001). Baseline National Institute of Health Stroke Scale (NIHSS) score was higher (12.7 vs 3.5, P < .001) as was modified Rankin Scale (mRS) score (3.5 vs 1.9, P < .001) and Barthel Index was lower (51.9 vs 84.8, P < .001) day 7. VFD was associated with increased mortality on Kaplan-Meier plots. Hazard ratio was significantly higher for patients with VFD after adjusting for age, sex, employment prior to infarction, married prior to infarction, institutionalization prior to infarction, prior myocardial infarction, atrial fibrillation, smoking, Barthel Index score and i.v. thrombolysis with Cox regression (hazard ratios [HR] 1.30, CI 1.07-1.56, P = .007). CONCLUSIONS Having a visual field defect after ischemic stroke is independently associated with increased mortality. This should be addressed when selecting candidates for thrombolysis and in the rehabilitation process.
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Affiliation(s)
- K. M. Sand
- Department of Neurology; Institute for Clinical Medicine; University of Bergen; Bergen Norway
| | - H. Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Centre for Age-Related Medicine; Stavanger University Hospital; Stavanger Norway
| | - L. Thomassen
- Department of Neurology; Institute for Clinical Medicine; University of Bergen; Bergen Norway
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| | - J. M. Hoff
- Department of Neurology; Haukeland University Hospital; Bergen Norway
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Asdaghi N, Wang K, Ciliberti-Vargas MA, Gutierrez CM, Koch S, Gardener H, Dong C, Rose DZ, Garcia EJ, Burgin WS, Zevallos JC, Rundek T, Sacco RL, Romano JG. Predictors of Thrombolysis Administration in Mild Stroke: Florida-Puerto Rico Collaboration to Reduce Stroke Disparities. Stroke 2018; 49:638-645. [PMID: 29459397 DOI: 10.1161/strokeaha.117.019341] [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: 04/13/2017] [Revised: 11/17/2017] [Accepted: 12/15/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Mild stroke is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable among different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD registry (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). METHODS Among 73 712 prospectively enrolled patients with a final diagnosis of ischemic stroke or TIA from January 2010 to April 2015, we identified 7746 cases with persistent neurological symptoms and National Institutes of Health Stroke Scale ≤5 who arrived within 4 hours of symptom onset. Multilevel logistic regression analysis with generalized estimating equations was used to identify independent predictors of thrombolytic administration in the subgroup of patients without contraindications to thrombolysis. RESULTS We included 6826 cases (final diagnosis mild stroke, 74.6% and TIA, 25.4%). Median age was 72 (interquartile range, 21); 52.7% men, 70.3% white, 12.9% black, 16.8% Hispanic; and median National Institutes of Health Stroke Scale, 2 (interquartile range, 3). Patients who received thrombolysis (n=1281, 18.7%) were younger (68 versus 72 years), had less vascular risk factors (hypertension, diabetes mellitus, and dyslipidemia), had lower risk of prior vascular disease (myocardial infarction, peripheral vascular disease, and previous stroke), and had a higher presenting median National Institutes of Health Stroke Scale (4 versus 2). In the multilevel multivariable model, early hospital arrival (arrive by 0-2 hours versus ≥3.5 hours; odds ratio [OR], 8.16; 95% confidence interval [CI], 4.76-13.98), higher National Institutes of Health Stroke Scale (OR, 1.87; 95% CI, 1.77-1.98), aphasia at presentation (OR, 1.35; 95% CI, 1.12-1.62), faster door-to-computed tomography time (OR, 1.81; 95% CI, 1.53-2.15), and presenting to an academic hospital (OR, 2.02; 95% CI, 1.39-2.95) were independent predictors of thrombolysis administration. CONCLUSIONS Mild acutely presenting stroke patients are more likely to receive thrombolysis if they are young, white, or Hispanic and arrive early to the hospital with more severe neurological presentation. Identification of predictors of thrombolysis is important in design of future studies to assess the use of thrombolysis for mild stroke.
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Affiliation(s)
- Negar Asdaghi
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.).
| | - Kefeng Wang
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Maria A Ciliberti-Vargas
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Carolina Marinovic Gutierrez
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Sebastian Koch
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Hannah Gardener
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Chuanhui Dong
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - David Z Rose
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Enid J Garcia
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - W Scott Burgin
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Juan Carlos Zevallos
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Tatjana Rundek
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Ralph L Sacco
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
| | - Jose G Romano
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (N.A., K.W., M.A.C.-V., C.M.G., S.K., H.G., C.D., T.R., R.L.S., J.G.R.); Department of Neurology, University of South Florida School of Medicine, Tampa (D.Z.R., W.S.B.); Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan (E.J.G.); and Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami (J.C.Z.)
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Choi JC, Kim BJ, Han MK, Lee SJ, Kang K, Park JM, Park SS, Park TH, Cho YJ, Hong KS, Lee KB, Lee J, Ryu WS, Kim DE, Nah HW, Kim DH, Cha JK, Kim JT, Choi KH, Oh MS, Yu KH, Lee BC, Jang MS, Lee JS, Lee J, Bae HJ. Utility of Items of Baseline National Institutes of Health Stroke Scale as Predictors of Functional Outcomes at Three Months after Mild Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:1306-1313. [PMID: 28318959 DOI: 10.1016/j.jstrokecerebrovasdis.2017.01.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/10/2017] [Accepted: 01/28/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Predicting outcomes of acute stroke patients initially presenting with mild neurologic deficits is crucial in decision making regarding thrombolytic therapy. We examined the utility of individual National Institutes of Health Stroke Scale (NIHSS) score items or clusters of items as predictors of functional outcomes at 3 months after mild stroke. METHODS Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had baseline NIHSS scores less than or equal to 5. Functional outcomes at 3 months were dichotomized as favorable (modified RankinScale [mRS] score 0 or 1) or unfavorable (mRS 2-6). Individual NIHSS items, clusters of items, and the total score were tested for their ability to predict outcomes in multivariable models. Area under the receiver operating characteristic curve (AUC) was used to assess model performance. RESULTS Of the 2209 patients who met eligibility criteria, 588 (26.6%) exhibited unfavorable functional outcomes at 3 months. Of the 15 items of the NIHSS, all except item 8 (sensory) and item 11 (extinction) were significantly associated with unfavorable functional outcomes in bivariate analysis (P's < .05). Among the multivariable models, the model with the total NIHSS score exhibited an AUC similar to that of the model with all NIHSS items in predicting functional outcomes (.758 [95% confidence interval .739-.775] versus .759 [.740-.776]; P = .75 for pairwise comparison). CONCLUSIONS Simply using the total NIHSS score was as effective as using all individual items in predicting outcomes of mild stroke patients.
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Affiliation(s)
- Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, Republic of Korea
| | - Kyusik Kang
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea
| | - Jong-Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Hyun-Wook Nah
- Department of Neurology, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Myung Suk Jang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.
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Reiff T, Michel P. Reasons and evolution of non-thrombolysis in acute ischaemic stroke. Emerg Med J 2016; 34:219-226. [PMID: 27797870 PMCID: PMC5502245 DOI: 10.1136/emermed-2015-205140] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/23/2016] [Accepted: 10/02/2016] [Indexed: 11/16/2022]
Abstract
Introduction Despite increasing evidence of its efficacy in advanced age or in mild or severe strokes, intravenous thrombolysis remains underused for acute ischaemic stroke (AIS). Our aim was to obtain an updated view of reasons for non-thrombolysis and to identify its changing patterns over time. Methods This is a retrospective study of prospectively collected data from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) from the years 2003–2011. Patients admitted with acute stroke in the past 24 hours who had not had thrombolysis were identified; reasons for non-thrombolysis documented in the prospectively entered data were tabulated and analysed for the group as a whole. Data were analysed for the years 2003–2006 and 2007 forward because of changes in contraindications. A subgroup of patients who arrived within the treatment window ≤180 min was separately analysed for reasons for non-thrombolysis. Predictors of non-thrombolysis were investigated via multivariate regression analyses. Results In the 2019 non-thrombolysed patients the most frequent reasons for non-thrombolysis were admission delays (66.3%), stroke severity (mostly mild) (47.9%) and advanced age (14.1%); 55.9% had more than one exclusion criterion. Among patients arriving ≤180 min after onset, the main reasons were stroke severity and advanced age. After 2006, significantly fewer patients were excluded because of age (OR 2.65, p<0.001) or (mostly mild) stroke severity (OR 10.56, p=0.029). Retrospectively, 18.7% of all non-thrombolysed patients could have been treated because they only had relative contraindications. Conclusion Onset-to-admission delays remain the main exclusion criterion for thrombolysis. Among early arrivals, relative contraindications such as minor stroke severity and advanced age were frequent. Thrombolysis rate increased with the reduction of thrombolysis restrictions (eg, age and stroke severity).
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Affiliation(s)
- T Reiff
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - P Michel
- Stroke Center, Neurology Service, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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Yakhkind A, McTaggart RA, Jayaraman MV, Siket MS, Silver B, Yaghi S. Minor Stroke and Transient Ischemic Attack: Research and Practice. Front Neurol 2016; 7:86. [PMID: 27375548 PMCID: PMC4901037 DOI: 10.3389/fneur.2016.00086] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/23/2016] [Indexed: 12/29/2022] Open
Abstract
A majority of patients with ischemic stroke present with mild deficits for which aggressive management is not often pursued. Comprehensive work-up and appropriate intervention for minor strokes and transient ischemic attacks (TIAs) point toward better patient outcomes, lower costs, and fewer cases of disability. Imaging is a key modality to guide treatment and predict stroke recurrence. Patients with large vessel occlusions have been found to suffer worse outcomes and could benefit from intervention. Whether intravenous thrombolytic therapy decreases disability in minor stroke patients and whether acute endovascular intervention improves functional outcomes in patients with minor stroke and known large vessel occlusion remain controversial. Studies are ongoing to determine ideal antiplatelet therapy for stroke and TIA, while ongoing statin therapy, surgical management for patients with carotid stenosis, and anticoagulation for patients with atrial fibrillation have all been proven to decrease the rate of stroke recurrence and improve outcomes. This review summarizes the current evidence and discusses the standard of care for patients with minor stroke and TIA.
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Affiliation(s)
- Aleksandra Yakhkind
- Department of Neurology, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Ryan A McTaggart
- Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Mahesh V Jayaraman
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Matthew S Siket
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Brian Silver
- Department of Neurology, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University , Providence, RI , USA
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Yaghi S, Willey JZ, Andrews H, Boehme AK, Marshall RS, Boden-Albala B. The Itemized NIHSS Scores Are Associated With Discharge Disposition in Patients With Minor Stroke. Neurohospitalist 2016; 6:102-6. [PMID: 27366292 DOI: 10.1177/1941874416641466] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE The ability of the National Institutes of Health Stroke Scale (NIHSS) score to predict functional outcome in minor stroke is controversial. In this study, we examined the association of itemized NIHSS score with discharge outcome. METHODS We included all patients with final diagnosis of stroke with an NIHSS score of 0 to 5 untreated with thrombolysis enrolled in the "Stroke Warning Information and Faster Treatment" trial. Individual components of the NIHSS score were the primary predictors. Poor outcome was defined as not being discharged home. Logistic regression was used to identify predictors of outcome. RESULTS A total of 861 patients met the inclusion criteria; 162 (19%) were not discharged home. In multivariable regression, predictors of discharge other than home were age (odds ratio [OR] = 1.02 per year increase, P < .001) and total NIHSS score (OR per unit increase in the NIHSS = 1.51, P < .001). Motor (OR = 2.32, P < .001), level of consciousness (LOC; OR = 6.62, P = .004), and ataxia (OR = 3.10, P < .001) were also associated with not being discharged home. Motor (area under the curve [AUC] 0.623) appeared to be more predictive of poor outcome than ataxia (AUC 0.569) and LOC (AUC 0.517). The total NIHSS had a fair correlation with discharge outcome (AUC 0.683). CONCLUSION Total and itemized NIHSS components have a fair correlation with outcome in minor stroke highlighting the importance of other measures of stroke severity for clinical trials.
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Affiliation(s)
- Shadi Yaghi
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Columbia University Medical Center, New York, NY, USA; Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Joshua Z Willey
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Howard Andrews
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Amelia K Boehme
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Randolph S Marshall
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Bernadette Boden-Albala
- Division of Social Epidemiology, Department of Neurology, Global Institute of Public Health, NYU Langone Medical Center, New York, NY, USA; Department of Epidemiology, College of Dentistry, New York University, New York, NY, USA
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Yaghi S, Willey JZ, Khatri P. Minor ischemic stroke: Triaging, disposition, and outcome. Neurol Clin Pract 2016; 6:157-163. [PMID: 27104067 PMCID: PMC4828677 DOI: 10.1212/cpj.0000000000000234] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 11/16/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Two-thirds of patients with stroke have mild deficits. The optimal triaging of these patients remains unclear. It is crucial to stratify patients based on who needs inpatient vs outpatient evaluation in a cost-effective manner. METHODS We reviewed the current literature (randomized trials, retrospective studies, case series, and case reports) on minor ischemic stroke and extrapolated evidence-based opinions and future directions on the management of minor ischemic stroke. RESULTS We provide evidence-based opinions and future directions on the approach to triaging patients with mild deficits based on the early risk of stroke recurrence, feasibility of outpatient diagnostic evaluation, and disabling deficits needing inpatient evaluation by physical and occupational therapy. CONCLUSIONS Outpatient evaluation of patients with nondisabling minor stroke is potentially cost-effective after excluding large artery atherosclerosis and ensuring a rapid access outpatient evaluation. Larger studies on the cost-effectiveness and safety of this approach are necessary.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, Division of Stroke and Cerebrovascular Diseases (SY), The Alpert Medical School of Brown University, Providence, RI; Department of Neurology, Division of Stroke and Cerebrovascular Diseases (JZW), Columbia University Medical Center, New York, NY; and Department of Neurology, Division of Stroke and Cerebrovascular Diseases (PK), University of Cincinnati, OH
| | - Joshua Z Willey
- Department of Neurology, Division of Stroke and Cerebrovascular Diseases (SY), The Alpert Medical School of Brown University, Providence, RI; Department of Neurology, Division of Stroke and Cerebrovascular Diseases (JZW), Columbia University Medical Center, New York, NY; and Department of Neurology, Division of Stroke and Cerebrovascular Diseases (PK), University of Cincinnati, OH
| | - Pooja Khatri
- Department of Neurology, Division of Stroke and Cerebrovascular Diseases (SY), The Alpert Medical School of Brown University, Providence, RI; Department of Neurology, Division of Stroke and Cerebrovascular Diseases (JZW), Columbia University Medical Center, New York, NY; and Department of Neurology, Division of Stroke and Cerebrovascular Diseases (PK), University of Cincinnati, OH
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Romano JG, Smith EE, Liang L, Gardener H, Campo-Bustillo I, Khatri P, Bhatt DL, Fonarow GC, Sacco RL, Schwamm LH. Distinct Short-Term Outcomes in Patients With Mild Versus Rapidly Improving Stroke Not Treated With Thrombolytics. Stroke 2016; 47:1278-85. [PMID: 26987870 DOI: 10.1161/strokeaha.115.011528] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 02/24/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Mild stroke (MS) and rapidly improving stroke (RIS) symptoms are common stroke presentations. Our objective is to describe the short-term outcomes in this population. METHODS A retrospective analysis of patients with ischemic stroke in the Get With The Guidelines-Stroke registry who arrived ≤4.5 hours from symptom onset not treated with thrombolytics because of MS and RIS. Outcomes included in-hospital death, home discharge, independent ambulation at discharge, and length of stay; these were analyzed for the categories of MS, RIS, and MS+RIS. Multivariable models evaluated the associations of individual and hospital covariates with outcomes. RESULTS Among 42 394 patients with MS and RIS not treated with thrombolytics, 27% were not discharged directly home, 27.2% did not ambulate independently, and 61.1% had length of stay ≥3 days, despite a low in-hospital mortality of 0.8%. Adjusted outcomes were better for MS+RIS compared with MS; RIS also had better independent ambulation and home discharge compared with MS. Among those with a documented National Institutes of Health Stroke Scale, 25% of those with National Institutes of Health Stroke Scale 0 to 5 and half of those with National Institutes of Health Stroke Scale >5 could not be discharged directly to home or ambulate independently. Older individuals, women, blacks, transport by ambulance, delayed arrival, greater severity and greater burden of vascular risk factors, except for dyslipidemia, had worse adjusted outcomes for home discharge and independent ambulation. CONCLUSIONS A significant proportion of patients with MS and RIS not treated with thrombolytics have suboptimal discharge outcomes. We found significant differences between MS, RIS, and MS+RIS and identified factors associated with worse outcomes.
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Affiliation(s)
- Jose G Romano
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.).
| | - Eric E Smith
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Li Liang
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Hannah Gardener
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Iszet Campo-Bustillo
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Pooja Khatri
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Deepak L Bhatt
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Gregg C Fonarow
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Ralph L Sacco
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Lee H Schwamm
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
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Adelman EE, Scott PA, Skolarus LE, Fox AK, Frederiksen SM, Meurer WJ. Protocol Deviations before and after Treatment with Intravenous Tissue Plasminogen Activator in Community Hospitals. J Stroke Cerebrovasc Dis 2015; 25:67-73. [PMID: 26419527 DOI: 10.1016/j.jstrokecerebrovasdis.2015.08.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 07/24/2015] [Accepted: 08/23/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Protocol deviations before and after tissue plasminogen activator (tPA) treatment for ischemic stroke are common. It is unclear if patient or hospital factors predict protocol deviations. We examined predictors of protocol deviations and the effects of protocol violations on symptomatic intracerebral hemorrhage (sICH). METHODS We used data from the Increasing Stroke Treatment through Interventional Behavior Change Tactics trial, a cluster-randomized, controlled trial evaluating the efficacy of a barrier assessment and educational intervention to increase appropriate tPA use in 24 Michigan community hospitals, to review tPA treatments between 2007 and 2010. Protocol violations were defined as deviations from the standard tPA protocol, both before and after treatment. Multilevel logistic regression models were fitted to determine if patient and hospital variables were associated with pretreatment or post-treatment protocol deviations. RESULTS During the study, 557 patients (mean age 70, 52% male, median National Institutes of Health Stroke Scale score 12) were treated with tPA. Protocol deviations occurred in 233 (42%) patients: 16% had pretreatment deviations, 35% had post-treatment deviations, and 9% had both. The most common protocol deviations included elevated post-treatment blood pressure, antithrombotic agent use within 24 hours of treatment, and elevated pretreatment blood pressure. Protocol deviations were not associated with sICH, stroke severity, or hospital factors. Older age was associated with pretreatment protocol deviations (adjusted odds ratio [OR], .52; 95% confidence interval [CI], .30-.92). Pretreatment deviations were associated with post-treatment deviations (adjusted OR, 3.20; 95% CI, 1.91-5.35). CONCLUSIONS Protocol deviations were not associated with sICH. Aside from age, patient and hospital factors were not associated with protocol deviations.
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Affiliation(s)
- Eric E Adelman
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Phillip A Scott
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Lesli E Skolarus
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Allison K Fox
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Shirley M Frederiksen
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
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Kenmuir CL, Hammer M, Jovin T, Reddy V, Wechsler L, Jadhav A. Predictors of Outcome in Patients Presenting with Acute Ischemic Stroke and Mild Stroke Scale Scores. J Stroke Cerebrovasc Dis 2015; 24:1685-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/18/2015] [Accepted: 03/29/2015] [Indexed: 11/26/2022] Open
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Spokoyny I, Raman R, Ernstrom K, Khatri P, Meyer DM, Hemmen TM, Meyer BC. Defining mild stroke: outcomes analysis of treated and untreated mild stroke patients. J Stroke Cerebrovasc Dis 2015; 24:1276-81. [PMID: 25906938 PMCID: PMC4457618 DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.037] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/21/2015] [Accepted: 01/30/2015] [Indexed: 11/26/2022] Open
Abstract
Introduction Mild deficit is a relative contraindication to administration of IV rtPA for acute ischemic stroke. However, what constitutes “mild” deficit is vague. Prior studies showed patients with mild strokes have substantial disability rates at hospital discharge and at 90 days. We investigated whether the application of a new definition altered the rates of disability overall, and assessed the effects of thrombolysis. Methods This analysis included all adult acute ischemic stroke patients from a prospective registry of consecutive patients (UCSD SPOTRIAS database, 2003-2014) with 90-day mRS score available who were defined as “mild” using either: NIHSS 0-5 or a TREAT Task Force definition (NIHSS 0-5 and non-disabling based on pre-specified syndromes). Dichotomized 90-day mRS were compared between treated and untreated patients using the two definitions. Results Of 802 ischemic stroke patients with mRS scores available, 184 had baseline mRS(0) and met TREAT criteria; 45(24.5%) were rtPA-treated. Among treated patients, 35.6% had 90-day mRS(2-6), versus 28.8% in the untreated group, a non-significant difference after adjusting for baseline NIHSS (p=0.47). None of the 45 treated patients had symptomatic hemorrhage. Outcomes were similar using the simpler NIHSS 0-5 definition. Conclusions About one-third of mild stroke patients were not functionally independent at 90 days, irrespective of treatment or mild definition applied, calling into question the treatment efficacy of IV rtPA for mild strokes as well as what constitutes an appropriate definition of “mild”. Randomized studies are necessary to determine rtPA treatment efficacy in mild stroke patients.
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Affiliation(s)
- Ilana Spokoyny
- Department of Neurology, University of California, San Diego, San Diego, California.
| | - Rema Raman
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
| | - Karin Ernstrom
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Dawn M Meyer
- Department of Neurology, University of California, San Diego, San Diego, California
| | - Thomas M Hemmen
- Department of Neurology, University of California, San Diego, San Diego, California
| | - Brett C Meyer
- Department of Neurology, University of California, San Diego, San Diego, California
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Strambo D, Zambon AA, Roveri L, Giacalone G, Di Maggio G, Peruzzotti-Jametti L, La Gioia S, Galantucci S, Comi G, Sessa M. Defining minor symptoms in acute ischemic stroke. Cerebrovasc Dis 2015; 39:209-15. [PMID: 25791530 DOI: 10.1159/000375151] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 01/12/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thrombolysis is often withheld from acute ischemic stroke patients presenting with mild symptoms; however, up to 40% of these patients end up with a poor outcome when left untreated. Since there is lack of consensus on the definition of minor symptoms, we aimed at addressing this issue by looking for features that would better predict functional outcomes at 3 months. METHODS Among all acute ischemic stroke patients admitted to our Stroke Unit (n = 1,229), we selected a cohort of patients who arrived within 24 hours from symptoms onset, with baseline NIHSS ≤6, not treated with thrombolysis (n = 304). Epidemiological data, comorbidities, radiological features and clinical presentation (NIHSS items) were collected to identify predictors of outcome. Our cohort was tested against minor stroke definitions selected from the literature and a newly proposed one. RESULTS Three months after stroke onset, 97 patients (31.9%) had mRS ≥ 2. Independent predictors of poor outcome were age (OR 0.97 [95% CI 0.95-9.99]) and baseline NIHSS score (OR 0.79 [95% CI 0.67-0.94]), while cardioembolic aetiology was negatively associated (OR 3.29 [95% CI 1.51-7.14]). Items of NIHSS associated with poor outcome were impairment of right motor arm (OR 0.49 [95% CI 0.27-0.91]) or the involvement of any of the motor items (OR 0.69 [95% CI 0.48-0.99]). The definition of minor stroke as NIHSS ≤3 and the new proposed definition had the highest sensitivity and accuracy and were independent predictors of outcome. CONCLUSIONS Our study confirmed that in spite of a low NIHSS score, one third of patients had poor outcome. As already described, age and NIHSS score remained independent predictors of poor outcome even in mild stroke. Also, motor impairment appeared a major determinant of poor outcome. The new proposed definition of minor stroke featured the NIHSS score and the NIHSS items that better predicted functional outcome. Awareness that even minor stroke can yield to poor outcome should sensitize patients to arrive early to the ED and neurologists to administer rt-PA.
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Affiliation(s)
- Davide Strambo
- San Raffaele Scientific Institute-Institute of Experimental Neurology, Stroke Unit-Department of Neurology and Neurophysiology, Milan, Italy
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Masingue M, Alamowitch S. [An update on limitations of intravenous thrombolysis to treat acute ischemic stroke]. Presse Med 2015; 44:515-25. [PMID: 25697630 DOI: 10.1016/j.lpm.2014.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/06/2014] [Accepted: 07/08/2014] [Indexed: 11/15/2022] Open
Abstract
The benefit of intravenous thrombolysis with rt-pa has been demonstrated in acute ischemic stroke up to 4 h 30 after the first symptoms. The number of patients with stroke treated by rt-pa remains low at less than 5%. In the license of rt-pa in acute ischemic stroke, there are numerous contra-indications explained by the fear of cerebral hemorrhagic complications. These contra-indications are based on the first therapeutic trials published more than 15 years ago, but are not all evidence-based. Large post-marketing registers and new randomized trials have shown a favorable ratio benefit/risk of rt-pa in acute ischemic strokes in some classical contra-indications. Reconsidering some of the official contra-indications would increase the target population with treatable acute ischemic stroke using rt-pa to 20%.
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Affiliation(s)
- Marion Masingue
- Hôpital Saint-Antoine, service de neurologie et d'urgences neuro-vasculaires, 75012 Paris, France
| | - Sonia Alamowitch
- Hôpital Saint-Antoine, service de neurologie et d'urgences neuro-vasculaires, 75012 Paris, France; Université Pierre-et-Marie-Curie, Paris VI, 75005 Paris, France.
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Urra X, San Román L, Gil F, Millán M, Cánovas D, Roquer J, Cardona P, Ribó M, Martí-Fàbregas J, Abilleira S, Chamorro Á. Medical and endovascular treatment of patients with large vessel occlusion presenting with mild symptoms: an observational multicenter study. Cerebrovasc Dis 2014; 38:418-24. [PMID: 25472576 DOI: 10.1159/000369121] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 10/15/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A significant proportion of stroke patients presenting with mild symptoms does not have a successful recovery, especially when a large vessel is occluded. IV thrombolysis is safe and may benefit patients presenting with mild symptoms. In this study, we tested whether endovascular therapy (ET) is superior to medical therapy in these patients. METHODS Observational, prospectively collected, multicenter study of 78 consecutive patients admitted from 2009 to 2012 within 6 h of stroke, with NIHSS≤5 at presentation or during initial diagnostic work-up and large vessel occlusion. Data for patients undergoing ET and/or IV thrombolysis were taken from the SONIIA registry of reperfusion therapies in Catalonia, or from our local stroke registry if no reperfusion therapy was delivered. We compared risk factors, clinical course, collateral circulation, revascularization rates, hemorrhagic complications, infarct volume, and the functional outcome at 3 months of patients treated with ET and those not receiving ET. Ordinal regression was used to assess the independent effect of ET on functional outcome. RESULTS Baseline characteristics were similar for ET (n=34) and medically (n=44) treated patients, except for older age in the latter. The occlusions were located in the terminal internal carotid artery (1%), M1 segment of the middle cerebral artery (33%), M2 segment (30%), posterior circulation (31%), and 5% of the patients had tandem lesions, with no significant differences between groups. Most patients in both treatment groups had good collateral flow. The rate of successful revascularization (91.2 vs. 63.4%; p=0.006) and the risk of symptomatic intracranial hemorrhage (11.8 vs. 0%; p=0.033) were higher in the ET group. The NIHSS scores were similar at hospital arrival, after initial neuroimaging, and at 24 h in both treatment groups and there were no significant differences in the infarct volume in a follow-up MRI. At 3 months, 35.9% of the patients had some disability. The functional outcome was similar in both treatment groups in univariate analysis and also in models adjusted for age and initial NIHSS or for variables associated to functional outcome on univariate comparison. Conversely, IV thrombolysis was associated with significantly greater chances of full recovery after adjusting for baseline differences (OR 3.70, p=0.015). CONCLUSIONS One third of stroke patients with mild symptoms and large vessel occlusions do not have a successful recovery. ET is effective to recanalize the occluded vessel but increases the risk of serious bleeding significantly without improving the functional outcome, and is therefore not justified routinely in these patients.
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Affiliation(s)
- Xabier Urra
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
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Zhu W, Churilov L, Campbell BC, Lin M, Liu X, Davis SM, Yan B. Does Large Vessel Occlusion Affect Clinical Outcome in Stroke with Mild Neurologic Deficits after Intravenous Thrombolysis? J Stroke Cerebrovasc Dis 2014; 23:2888-2893. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/28/2014] [Accepted: 07/11/2014] [Indexed: 11/29/2022] Open
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Villringer K, Grittner U, Schaafs LA, Nolte CH, Audebert H, Fiebach JB. IV t-PA influences infarct volume in minor stroke: a pilot study. PLoS One 2014; 9:e110477. [PMID: 25350762 PMCID: PMC4211677 DOI: 10.1371/journal.pone.0110477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 09/13/2014] [Indexed: 11/18/2022] Open
Abstract
Background There is an ongoing debate whether stroke patients presenting with minor or moderate symptoms benefit from thrombolysis. Up until now, stroke severity on admission is typically measured with the NIHSS, and subsequently used for treatment decision. Hypothesis Acute MRI lesion volume assessment can aid in therapy decision for iv-tPA in minor stroke. Methods We analysed 164 patients with NIHSS 0–7 from a prospective stroke MRI registry, the 1000+ study (clinicaltrials.org NCT00715533). Patients were examined in a 3 T MRI scanner and either received (n = 62) or did not receive thrombolysis (n = 102). DWI (diffusion weighted imaging) and PI (perfusion imaging) at admission were evaluated for diffusion - perfusion mismatch. Our primary outcome parameter was final lesion volume, defined by lesion volume on day 6 FLAIR images. Results The association between t-PA and FLAIR lesion volume on day 6 was significantly different for patients with smaller DWI volume compared to patients with larger DWI volume (interaction between DWI and t-PA: p = 0.021). Baseline DWI lesion volume was dichotomized at the median (0.7 ml): final lesion volume at day 6 was larger in patients with large baseline DWI volumes without t-PA treatment (median difference 3, IQR −0.4–9.3 ml). Conversely, in patients with larger baseline DWI volumes final lesion volumes were smaller after t-PA treatment (median difference 0, IQR −4.1–5 ml). However, this did not translate into a significant difference in the mRS at day 90 (p = 0.577). Conclusion Though this study is only hypothesis generating considering the number of cases, we believe that the size of DWI lesion volume may support therapy decision in patients with minor stroke. Trial Registration Clinicaltrials.org NCT00715533
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Affiliation(s)
- Kersten Villringer
- Academic Neuroradiology, Department of Neurology and Center for Stroke Research, Charité, Berlin, Germany
- * E-mail:
| | - Ulrike Grittner
- Department for Biostatistics and Clinical Epidemiology and Center for Stroke Research, Charité, Berlin, Germany
| | - Lars-Arne Schaafs
- Academic Neuroradiology, Department of Neurology and Center for Stroke Research, Charité, Berlin, Germany
| | - Christian H. Nolte
- Department of Neurology and Center for Stroke Research, Charité, Berlin, Germany
| | - Heinrich Audebert
- Department of Neurology and Center for Stroke Research, Charité, Berlin, Germany
| | - Jochen B. Fiebach
- Academic Neuroradiology, Department of Neurology and Center for Stroke Research, Charité, Berlin, Germany
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Sato S, Uehara T, Ohara T, Suzuki R, Toyoda K, Minematsu K. Factors associated with unfavorable outcome in minor ischemic stroke. Neurology 2014; 83:174-81. [PMID: 24907232 DOI: 10.1212/wnl.0000000000000572] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The purpose of this study was to elucidate the factors that correlate with unfavorable outcomes and to develop a simple validated model for assessing risk of unfavorable outcomes in patients with minor ischemic stroke. METHODS The derivation cohort included 1,313 patients hospitalized within 72 hours after onset with an initial NIH Stroke Scale score of 0 to 3 enrolled in a prospective, multicenter, observational study. Unfavorable outcome was defined as dependency (modified Rankin Scale score of 3-5) or death at 90 days. The predictive values of factors related to unfavorable outcome were evaluated. External validation was performed in 879 patients from a single-center stroke registry. RESULTS In the derivation cohort, a total of 203 patients (15%) had unfavorable outcomes. On multivariable analysis, women (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.30-2.94), age ≥72 years (OR 2.80, 95% CI 1.83-4.36), intra/extracranial vascular occlusive lesion (OR 2.80, 95% CI 1.82-4.28), leg weakness (OR 1.72, 95% CI 1.06-2.82), and extinction/inattention (OR 5.55, 95% CI 1.30-21.71) were independently associated with unfavorable outcome. Patients having both a vascular lesion and either leg weakness or extinction/inattention showed 4.63 (95% CI 2.23-9.33) times the risk of unfavorable outcome compared with those having neither. In the validation cohort, the risk was similar, at 3.77 (95% CI 1.64-8.37). CONCLUSIONS Intra- and extracranial vascular imaging, NIH Stroke Scale items such as leg weakness and extinction/inattention, and their combination, as well as female sex and advanced age, may be useful for predicting unfavorable outcomes in patients with minor stroke.
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Affiliation(s)
- Shoichiro Sato
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Toshiyuki Uehara
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomoyuki Ohara
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Rieko Suzuki
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazunori Toyoda
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazuo Minematsu
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Fugate JE, Rabinstein AA. Contraindications to intravenous rtPA for acute stroke: A critical reappraisal. Neurol Clin Pract 2013; 3:177-185. [PMID: 29473642 DOI: 10.1212/cpj.0b013e318296f0a9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Only 1%-5% of patients with acute ischemic stroke presenting within 3 hours of symptoms receive IV recombinant tissue plasminogen activator (rtPA)-the only effective treatment available. The administration of rtPA is limited by extensive exclusion criteria, many of which are not based on evidence, but rather derived from expert opinion for large stroke trials. Over the past 15 years, experiences with the use of rtPA in clinical practice have led to evidence suggesting that several of the current contraindications for rtPA are unnecessary and overly restrictive. In this review, we analyze the evidence-most of which is derived from observational research-supporting or contradicting current contraindications for administering IV rtPA to acute ischemic stroke patients.
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Sucharew H, Khoury J, Moomaw CJ, Alwell K, Kissela BM, Belagaje S, Adeoye O, Khatri P, Woo D, Flaherty ML, Ferioli S, Heitsch L, Broderick JP, Kleindorfer D. Profiles of the National Institutes of Health Stroke Scale items as a predictor of patient outcome. Stroke 2013; 44:2182-7. [PMID: 23704102 DOI: 10.1161/strokeaha.113.001255] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Initial National Institutes of Health Stroke Scale (NIHSS) score is highly predictive of outcome after ischemic stroke. We examined whether grouping strokes by presence of individual NIHSS symptoms could provide prognostic information additional or alternative to the NIHSS total score. METHODS Ischemic strokes from the Greater Cincinnati Northern Kentucky Stroke Study in 2005 were used to develop the model. Latent class analysis was implemented to form groups of patients with similar retrospective NIHSS (rNIHSS) item responses. Profile group was then used as an independent predictor of discharge modified Rankin and mortality, using logistic regression and Cox proportional hazards model. RESULTS A total of 2112 stroke patients were identified in 2005. Six distinct profiles were characterized. Consistent with the profile patterns, the median rNIHSS total score decreased from profile A "most severe" (median [interquartile range], 20 [15-25]) to profile F "mild" (1[1-2]). Two profiles falling between these extremes, C and D, both had median rNIHSS total score of 5, but different survival rates. Compared with A, C was associated with 59% risk reduction for death, whereas D with 70%. C patients were more likely to have decreased level of consciousness and abnormal language, whereas D patients were more likely to have abnormal right arm and right leg motor function. CONCLUSIONS Six rNIHSS profiles were identifiable using latent class analysis. In particular, 2 symptom profiles with identical median rNIHSSS were observed with widely disparate outcomes, which may prove useful both clinically and for research studies as an enhancement to the overall NIHSS score.
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Affiliation(s)
- Heidi Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
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Validation of minor stroke definitions for thrombolysis decision making. J Stroke Cerebrovasc Dis 2013; 22:482-90. [PMID: 23545318 DOI: 10.1016/j.jstrokecerebrovasdis.2013.03.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/27/2013] [Accepted: 03/05/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients with low National Institutes of Health Stroke Scale (NIHSS) scores are frequently excluded from thrombolysis, but more than 25% of them remain disabled. We sought to define a validated minor stroke definition to reduce the inappropriate treatment exclusion. METHODS From an outcome database, untreated patients with an NIHSS score of 5 or less presenting within a 4.5-hour window were identified and 3-month modified Rankin Scale (mRS) outcomes were analyzed according to individual isolated symptoms and total NIHSS scores. The validity of the following minor stroke definitions were assessed: (1) the National Institute of Neurological Disorders and Stroke Tissue Plasminogen Activator (NINDS-TPA) trials' definition, (2) the total NIHSS score, varying a cutoff point from 0 to 4, and (3) our proposed definition that included an NIHSS score = 0 or an NIHSS score = 1 on the items of level of consciousness (LOC), gaze, facial palsy, sensory, or dysarthria. RESULTS Of 647 patients, 172 patients (26.6%) had a 3-month unfavorable outcome (mRS score 2-6). Favorable outcome was achieved in more than 80% of patients with an NIHSS score of 1 or less or with an isolated symptom on the LOC, gaze, facial palsy, sensory, or dysarthria item. In contrast, unfavorable outcome proportion was more than 25% in patients with an NIHSS score of 2 or more. When the NINDS-TPA trials' definition, our definition, or the definition of an NIHSS score of 1 or less were applied, more than 75% of patients with an unfavorable outcome were defined as a non-minor stroke and less than 15% of patients with an unfavorable outcome were defined as a minor stroke. CONCLUSION Implementation of an optimal definition of minor stroke into thrombolysis decision-making process would decrease the unfavorable outcomes in patients with low NIHSS scores.
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Urra X, Ariño H, Llull L, Amaro S, Obach V, Cervera Á, Chamorro Á. The outcome of patients with mild stroke improves after treatment with systemic thrombolysis. PLoS One 2013; 8:e59420. [PMID: 23527192 PMCID: PMC3602063 DOI: 10.1371/journal.pone.0059420] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 02/14/2013] [Indexed: 01/30/2023] Open
Abstract
Introduction In up to one third of patients with mild stroke suitable to receive systemic thrombolysis the treatment is not administered because the treating physicians estimate a good spontaneous recovery. However, it is not settled whether the fate of these patients is equivalent to those who are thrombolysed. Methods We analyzed 203 consecutive patients (134 men and 69 women, mean age 69±14 years) without premorbid disability and a NIHSS score ≤5 at admission [median 3 (IQR 2–4)]. Intravenous thrombolysis was administered within 4.5 hours from stroke onset (n = 119), or it was withheld (n = 84) whenever the treating physician predicted a spontaneous recovery. The baseline risk factors, clinical course, infarction volume, bleeding complications, and functional outcome at 3 months were analyzed and declared to a Web-based registry which was accessible to the local Health Authorities. Results Expectedly, not thrombolysed patients had the mildest strokes at admission [median 2 (IQR 1–3.75)]. At day 2 to 5, the infarct volume on DWI-MRI was similar in both groups. There were no symptomatic cerebral bleedings in the study. An ordinal regression model adjusted for baseline stroke severity showed that thrombolysis was associated with a greater proportion of patients who shifted down on the modified Rankin Scale score at 3 months (OR 2.66; 95% CI 1.49–4.74, p = 0.001). Conclusions Intravenous thrombolysis seems to be safe in patients with mild stroke and may be associated with improved outcome compared with untreated patients. These results support the evaluation of the efficacy of intravenous thrombolysis in mild stroke patients in randomized clinical trials.
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Affiliation(s)
- Xabier Urra
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
- Institut d’Investigacions Biomediques August Pi i Sunyer, Barcelona, Spain
| | - Helena Ariño
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
| | - Laura Llull
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
| | - Sergio Amaro
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
- Institut d’Investigacions Biomediques August Pi i Sunyer, Barcelona, Spain
| | - Víctor Obach
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
| | - Álvaro Cervera
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
- Institut d’Investigacions Biomediques August Pi i Sunyer, Barcelona, Spain
| | - Ángel Chamorro
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
- Institut d’Investigacions Biomediques August Pi i Sunyer, Barcelona, Spain
- Medicine Department, School of Medicine, Universitat de Barcelona, Barcelona, Spain
- * E-mail:
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Aphasia predicts unfavorable outcome in mild ischemic stroke patients and prompts thrombolytic treatment. J Stroke Cerebrovasc Dis 2013; 23:204-8. [PMID: 23352114 DOI: 10.1016/j.jstrokecerebrovasdis.2012.11.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 11/14/2012] [Accepted: 11/19/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients with an acute ischemic stroke rated as mild, and for this reason not submitted to thrombolysis, have an unfavorable outcome in a non-negligible proportion. Whether selective presentation features help identify those at risk of bad outcome, and whether it could be recommended to treat only patients with such features, is poorly elucidated. We report our experience based on retrospective evaluation of a consecutive series of patients scoring 6 or less on baseline National Institutes of Health Stroke Scale (NIHSS), some of whom received thrombolysis. METHODS From the prospective Careggi Hospital Stroke Registry, Florence, Italy, we selected a series of patients who fulfilled the following criteria: (1) screening for treatment within 3 hours of symptom onset; (2) mild symptoms, defined as a score of 6 or less on NIHSS, with or without rapid improvement; (3) no other reason for exclusion from thrombolysis; (4) no previous disability; and (5) admission to the stroke unit. We choose a modified Rankin scale score of less than 2 to define a good 3-month functional outcome. We studied as potential outcome predictors: age, baseline NIHSS score, isolated aphasia, motor impairment with or without aphasia, thrombolysis, previous stroke or transient ischemic attack, and interactions between each of these factors and thrombolysis. RESULTS Between February 2004 and June 2011, 128 patients fulfilled the selection criteria: 47 (36.7%) received tissue plasminogen activator, 81 (63.3%) did not. At 3 months, of the 81 patients not receiving tissue plasminogen activator, 14 (17.3%) had an unfavorable outcome, compared with 6 (12.8%) among the 47 treated. Hemorrhagic complications or death occurred in neither group. Adjusting for major confounders and for thrombolysis, the presence of aphasia on early assessment proved the only independent predictor of worse outcome. NIHSS score variation showed no effect. CONCLUSIONS Aphasia is an early marker of unfavorable outcome in mild ischemic stroke patients. In these patients thrombolysis should be considered beyond the NIHSS scoring.
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Solomons N, Nortje N. Treating an intervention level 1 patient: futile or brave? SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2013. [DOI: 10.1080/16070658.2013.11734469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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