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Bai Y, Belardinelli P, Thoennes C, Blum C, Baur D, Laichinger K, Lindig T, Ziemann U, Mengel A. Cortical reactivity to transcranial magnetic stimulation predicts risk of post-stroke delirium. Clin Neurophysiol 2023; 148:97-108. [PMID: 36526534 DOI: 10.1016/j.clinph.2022.11.017] [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: 09/28/2022] [Revised: 11/14/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Post-stroke delirium (PSD) is a frequent and with regard to outcome unfavorable complication in acute stroke. The neurobiological mechanisms predisposing to PSD remain poorly understood, and biomarkers predicting its risk have not been established. We tested the hypothesis that hypoexcitable or disconnected brain networks predispose to PSD by measuring brain reactivity to transcranial magnetic stimulation with electroencephalography (TMS-EEG). METHODS We conducted a cross-sectional study in 33 acute stroke patients within 48 hours of stroke onset. Brain reactivity to single-pulse TMS of dorsolateral prefrontal cortex, primary motor cortex and superior parietal lobule of the right hemisphere was quantified by response intensity, effective connectivity, perturbational complexity index (PCIST), and natural frequency of the TMS-EEG response. PSD development was clinically tracked every 8 hours before and for 7 days following TMS-EEG. RESULTS Fourteen patients developed PSD while 19 patients did not. The PSD group showed lower excitability, effective connectivity, PCIST and natural frequency compared to the non-PSD group. The maximum PCIST over all three TMS sites demonstrated largest classification accuracy with a ROC-AUC of 0.943. This effect was independent of lesion size, affected hemisphere and stroke severity. Maximum PCIST and maximum natural frequency correlated inversely with delirium duration. CONCLUSIONS Brain reactivity to TMS-EEG can unravel brain network states of reduced excitability, effective connectivity, perturbational complexity and natural frequency that identify acute stroke patients at high risk for development of delirium. SIGNIFICANCE Findings provide novel insight into the pathophysiology of pre-delirium brain states and may promote effective delirium prevention strategies in those patients at high risk.
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Affiliation(s)
- Yang Bai
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany; School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou, China
| | - Paolo Belardinelli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany; Center for Mind/Brain Sciences - CIMeC, University of Trento, Italy
| | - Catrina Thoennes
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Corinna Blum
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - David Baur
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Kornelia Laichinger
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Tobias Lindig
- Department of Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.
| | - Annerose Mengel
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
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Fialho Silva IT, Assis Lopes P, Timotio Almeida T, Ramos SC, Caliman Fontes AT, Guimarães Silva D, Martins Soares C, Oliveira Carneiro L, Souza IFB, Ferreira Abreu F, Nascimento Silva G, Mascarenhas de Souza L, Brito Pinheiro T, de Souza E Silva FN, de Santana JP, Kelly Silva B, Almeida Souza D, Silva Macedo S, Almeida Ismael LS, Pereira de Jesus PA. Impact of Delirium and Its Motor Subtypes on Stroke Outcomes. Stroke 2021; 52:1322-1329. [PMID: 33719516 DOI: 10.1161/strokeaha.120.026425] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Delirium is an acute and fluctuating impairment of attention, cognition, and behavior. Although common in stroke, studies that associate the clinical subtypes of delirium with functional outcome and death are lacking. We aimed to evaluate the influence of delirium occurrence and its different motor subtypes over stroke patients' prognosis. METHODS Prospective cohort of stroke patients with symptom onset within 72 hours before research admission. Delirium was diagnosed by Confusion Assessment Method for the Intensive Care Unit, and its motor subtypes were defined according to the Richmond Agitation-Sedation Scale. The main outcome was functional dependence or death (modified Rankin Scale>2) at 90 days comparing: delirium versus no delirium patients; and between motor subtypes. Secondary outcomes included modified Rankin Scale score >2 at 30 days and 90-day-mortality. RESULTS Two hundred twenty-seven patients were enrolled. Delirium occurred in 71 patients (31.3%), with the hypoactive subtype as the most frequent, in 41 subjects (57.8%). Delirium was associated with increased risk of death and functional dependence at 30 and 90 days and higher 90-day mortality. Multivariate analysis showed delirium (odds ratio, 3.28 [95% CI, 1.17-9.22]) as independent predictor of modified Rankin Scale >2 at 90 days. CONCLUSIONS Delirium is frequent in stroke patients in the acute phase. Its occurrence-specifically in mixed and hypoactive subtypes-seems to predict worse outcomes in this population. To our knowledge, this is the first study to prospectively investigate differences between delirium motor subtypes over functional outcome three months poststroke. Larger studies are needed to elucidate the relationship between motor subtypes of delirium and functional outcomes in the context of acute stroke.
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Affiliation(s)
- Ivã Taiuan Fialho Silva
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Pedro Assis Lopes
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Tiago Timotio Almeida
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Saint Clair Ramos
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Ana Teresa Caliman Fontes
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Daniel Guimarães Silva
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Camila Martins Soares
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Lays Oliveira Carneiro
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Ian Felipe Barbosa Souza
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Fernanda Ferreira Abreu
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Gabriel Nascimento Silva
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Letícia Mascarenhas de Souza
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Thiago Brito Pinheiro
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Filipe Nolasco de Souza E Silva
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - João Pedro de Santana
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Beatriz Kelly Silva
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Danilo Almeida Souza
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
| | - Silvana Silva Macedo
- Federal University of Bahia, Stroke Clinic, Salvador, Brazil (I.T.F.S., P.A.L., T.T.A., A.T.C.F., D.G.S., L.O.C., F.F.A., G.N.S., L.M.d.S., S.C.R., C.M.S., I.F.B.S., T.B.P., F.N.d.S.e.S., J.P.d.S., B.K.S., D.A.S., S.S.M.)
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