Complications in the first week after stroke: a 10-year comparison

C-reactive protein levels are associated with early cardiac complications or death in patients with acute ischemic stroke: a propensity-matched analysis of a global federated health from the TriNetX network

The role of inflammation in predicting early cardiac complications among stroke patients is unclear. Electronic medical records from TriNetX, a global federated health research network, were used for this retrospective analysis. Patients with ischemic stroke and C-Reactive Protein (CRP) levels measured within 24 h post-stroke were categorized into three groups: (i) < 1 mg/L, (ii)1-3 mg/L and (iii) > 3 mg/L. The primary outcome was a composite outcome of cardiac complications (heart failure (HF), ischemic heart disease, atrial fibrillation (AF), ventricular arrhythmias and Takotsubo cardiomyopathy) or death at 30 days from the index event. Cox-regression analyses were used to produce hazard ratios (HRs) and 95% confidence intervals (CI) following 1:1 propensity score matching (PSM). Of the 104,741 patients enrolled, 51% were female and the mean age was 66 ± 16 years. After PSM, a new cardiac complication or death within 30 days occurred in 5624 (33.1%) patients with CRP > 3 mg/L, in 4243 (25.6%) patients with CRP 1-3 mg/L and in 3891 (23.5%) patients with CRP < 1 mg/L. Patients with CRP levels of 1-3 mg/L and > 3 mg/L had higher risk of the composite outcome (HR 1.10, 95%CI 1.05-1.52; HR 1.51, 95%CI 1.45-1.58), death (HR 1.43, 95%CI 1.24-1.64; HR 3.50, 95%CI 3.01-3.96), HF (HR 1.08, 95%CI 1.01-1.16; HR 1.51, 95%CI 1.41-1.61), AF (HR 1.10, 95% CI:1.02-1.18; HR 1.42, 95%CI 1.33-1.52) and ventricular arrhythmias (HR 1.25, 95%CI 1.02-1.52; HR 1.67, 95% CI 1.38-2.01) compared to those with CRP < 1 mg/L. Ischemic heart disease were more common among patients with CRP levels > 3 mg/L compared to those with CRP < 1 mg/L (HR:1.33, 95% CI:1.26-1.40), while no association with Takotsubo cardiomyopathy was found in all the analyses. CRP levels within the first 24 h of an ischemic stroke predict 30-day cardiac complications or death.

Clinical characteristic of a Haitian stroke cohort and a scoping review of the literature of stroke among the Haitian population

Background and Aim

There are significant disparities in stroke care and outcomes between low- and middle-income countries compared to high-income countries. Haiti, a lower-middle-income country, suffers from a lack of resources for acute stroke management. This study is the first to report the epidemiological profile of the Haitian population presenting with stroke symptoms at the largest academic hospital in the nation.

Methods

This is an observational study conducted over a period of 5 months from April 2021 to August 2021 in the Internal Medicine Department of the State University Hospital of Haiti. There were 51 included patients who were suspected to have had an acute stroke. A descriptive statistical analysis was conducted. A scoping review of the literature was also conducted.

Results

Over 50% of included patients were between 19 and 65 years old. The mean age at presentation was 61 years, and patients were predominantly female (64.7%). The prevalence of severe motor deficits was over 96%. The mean National Institutes of Health Stroke Scale was 12. Only 15.7% of patients (8/51) had a computed tomography (CT) scan during their hospitalization. The median time to CT scan was 84 h after symptom onset. About 80% of those with complications took more than 24 h to arrive at the hospital after the onset of symptoms. Eleven percent of patients had complications, and the mortality rate was 3.9%. There was a significant association between the Modified Rankin Scale and the occurrence of complications (p = 0.016). National Institutes of Health Stroke Scale (NIHSS) score had a significant association with the Glasgow score (F = 6.3; p < 0.001) where an inversely proportional correlation was observed between them (r = -0.7; p < 0.001) and a proportional correlation with the Rankin prediction score and the NIHSS (r = 0.3, p = 0.04). Little is known about the epidemiology of stroke patients in Haiti, and this limits the ability to develop targeted interventions to improve outcomes. In our scoping review, only three pertinent studies were identified over a 25-year period, this leads to a lack of data in regard to stroke care in Haiti mainly due to the absence of trained personnel.

Conclusion

In our cohort, stroke is mainly affecting female patients. The majority of stroke patients have moderate to severe motor deficits and took more than 24 h to arrive at the hospital. Urgent assistance is needed to strengthen personnel and infrastructure dedicated to stroke. Neurological assessment based on NIHSS and Rankin score should be systematic in stroke evaluation in Haiti.

Relevance for Patients

This study is relevant for patients because it emphasizes the challenges of stroke management in Haiti due to the non-availability of reference drugs, the time to arrive at the hospital to start treatment, as well as the means of diagnosis which are limited, like the CT scan. While stroke prevalence is on the rise in the country, it is the highest in the Caribbean and Latin America region.

Nonpharmacological Treatments for Hospitalized Patients with Stroke: A Nuanced Approach to Prescribing Early Activity

Stroke remains a leading cause of adult disability. To date, hyperacute revascularization procedures reach 5-10% of stroke patients even in high resource health systems. There is a limited time window for brain repair after stroke, and therefore, the activities such as prescribed exercise in the earliest period will likely have long-term significant consequences. Clinicians who provide care for hospitalized stroke patients make treatment decisions specific to activity often without guidelines to direct these prescriptions. This requires a balanced understanding of the available evidence for early post-stroke exercise and physiological principles after stroke that drive the safety of prescribed exercise. Here, we provide a summary of these relevant concepts, identify gaps, and recommend an approach to prescribing safe and meaningful activity for all patients with stroke. The population of thrombectomy-eligible stroke patients can be used as the exemplar for conceptualization.

Transient ischemic attack events and incident cardiovascular and non-cardiovascular complications: Observations from a large diversified multimorbid cohort

Background:

Transient ischemic attack (TIA) is a strong signal prompting the incidence of future cardiovascular and non-cardiovascular complications, in light of recent debate on the so-called “stroke-heart syndrome.” We aimed to investigate the relation of TIAs to incident clinical events.

Methods:

Patients were drawn from three health plans with a wide spectrum of age groups and a wide mix of socio-economic/disability status. Two TIA cohorts in a retrospective design were used to achieve the study specific aims: (i) to investigate the incidence of TIA and associated cardiovascular and non-cardiovascular complications within 30 and 90 days from the onset of incident TIA events; and (ii) to examine the potential risk factors for developing incident TIA events in the general population with/without a history of prior stroke.

Results:

The incident TIA cohort consisted of 53,716 patients with an average age of 64.2 years (SD 15.2) and 46.1% male. Following TIA, the incidence proportions of ischemic stroke within 30 and 90 days were 2.7% and 3.8%, respectively, and for incident acute coronary syndrome being 0.94 and 1.84, respectively. Ventricular arrhythmia had proportions of 1.2 and 2.14, respectively within 30 and 90 days, with acute heart failure having values of 0.49 and 0.923. About 45% or more of the cardiovascular and non-cardiovascular complications occurred in the first 30 days following the incident TIA cases. About one-third of the recurrent TIA cases followed the incident TIA cases within a span of 30 days. Amongst comorbidities with stroke in the comorbid history, prior stroke provided the strongest risk factor in terms of odds ratio (OR = 8.34, 95% CI 7.21–9.66) for incident TIA events. Age was strongly associated with incident TIA events. Without a prior history of stroke (ischemic stroke/transient ischemic attack/thrombo-embolic events), valvular disease was the strongest risk factor from among the comorbidities (OR-1.87, 95% CI 1.51–2.32). Age also provided strong associations with incident TIA events.

Conclusions:

Following a TIA, there was a high risk of stroke, acute coronary syndrome, ventricular arrhythmia, acute heart failure, and non-cardiovascular complications.

Optimising rehabilitation and recovery after a stroke

Stroke can cause significant disability and impact quality of life. Multidisciplinary neurorehabilitation that meets individual needs can help to optimise recovery. Rehabilitation is essential for best quality care but should start early, be ongoing and involve effective teamwork. We describe current stroke rehabilitation processes, from the hyperacute setting through to inpatient and community rehabilitation, to long-term care and report on which UK quality care standards are (or are not) being met. We also examine the gap between what stroke rehabilitation is recommended and what is being delivered, and suggest areas for further improvement.

Stroke and Pneumonia: Mechanisms, Risk Factors, Management, and Prevention

A stroke is a cerebrovascular medical emergency characterized by the sudden loss of neurological function due to interruption to the blood supply. A serious and common complication of stroke is pneumonia. This review article outlined various studies in order to understand the pathogenesis pathways that lead to the development of stroke-associated pneumonia, as well as therapeutic and preventive options to reduce pneumonia. The article looked for risk factors that increase the risk of developing pneumonia among stroke patients. In addition, it has reviewed various therapeutic modalities, such as postural modifications, pharmacological treatment, and other unique treatments, in an attempt to find which of them are efficient to decrease the occurrence of pneumonia and which of them are not. The article also attempts to emphasize the importance of early screening for dysphagia among stroke patients and demonstrates the importance of preventive strategies that can be easily implemented, such as routine oral care and behavioral modifications.

Association between out-of-bed mobilization and complications of immobility in acute phase of severe stroke: A retrospective observational study

BACKGROUND

Medical complications often occur, particularly in the acute phase of severe stroke, and lead to poor outcomes. However, it is unclear whether out-of-bed mobilization (OM) reduces such complications or not in the acute phase of severe stroke. Thus, we investigated the association between OM and complications of immobility in the acute phase of severe stroke.

METHODS

We enrolled 407 patients diagnosed with ischemic stroke or intracerebral hemorrhage and patients with modified Rankin Scale 5 at discharge in this study. Patients were divided into two groups: OM (303 patients) and bed rest (BR; 104 patients) at discharge based on their medical records. Complications of immobility (such as pneumonia, urinary tract infection, pressure sore, and falls) during hospitalization in each group were recorded.

RESULTS

The total complication rate of immobility, incidence of pneumonia, and the incidence of pressure sores were significantly lower in the OM group than in the BR group [60.7% vs. 88.5%, 45.5% vs. 62.5%, and 3.6% vs. 12.5%; odds ratio, 0.20, 0.50, and 0.26; and 95% confidence intervals, 0.11-0.39, 0.32-0.79, and 0.11-0.61, respectively]. Urinary tract infection and falls did not differ significantly between the two groups.

CONCLUSIONS

In the acute phase of severe stroke, OM was significantly associated with a lower risk of total complication rate of immobility, incidence of pneumonia, and incidence of pressure sore without increasing falls.

Post-Ischaemic Immunological Response in the Brain: Targeting Microglia in Ischaemic Stroke Therapy

Microglia, the major endogenous immune cells of the central nervous system, mediate critical degenerative and regenerative responses in ischaemic stroke. Microglia become "activated", proliferating, and undergoing changes in morphology, gene and protein expression over days and weeks post-ischaemia, with deleterious and beneficial effects. Pro-inflammatory microglia (commonly referred to as M1) exacerbate secondary neuronal injury through the release of reactive oxygen species, cytokines and proteases. In contrast, microglia may facilitate neuronal recovery via tissue and vascular remodelling, through the secretion of anti-inflammatory cytokines and growth factors (a profile often termed M2). This M1/M2 nomenclature does not fully account for the microglial heterogeneity in the ischaemic brain, with some simultaneous expression of both M1 and M2 markers at the single-cell level. Understanding and regulating microglial activation status, reducing detrimental and promoting repair behaviours, present the potential for therapeutic intervention, and open a longer window of opportunity than offered by acute neuroprotective strategies. Pharmacological modulation of microglial activation status to promote anti-inflammatory gene expression can increase neurogenesis and improve functional recovery post-stroke, based on promising preclinical data. Cell-based therapies, using preconditioned microglia, are of interest as a method of therapeutic modulation of the post-ischaemic inflammatory response. Currently, there are no clinically-approved pharmacological options targeting post-ischaemic inflammation. A major developmental challenge for clinical translation will be the selective suppression of the deleterious effects of microglial activity after stroke whilst retaining (or enhancing) the neurovascular repair and remodelling responses of microglia.

Priority Nursing Interventions Caring for the Stroke Patient

Nearly 20% of all patients with ischemic stroke will require care in an intensive care unit (ICU), particularly those who have received intravenous alteplase or endovascular therapy. Prioritizing nursing intervention and intensive care monitoring can improve patient outcomes and reduce disability. A collaborative interdisciplinary team approach best facilitates the ICU care of an acute stroke patient.

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

Knowledge gaps exist in how we implement aerobic exercise programs during the early phases post-stroke. Therefore, the objective of this review was to provide evidence-based guidelines for pre-participation screening, mobilization, and aerobic exercise training in the hyper-acute and acute phases post-stroke. In reviewing the literature to determine safe timelines of when to initiate exercise and mobilization we considered the following factors: arterial blood pressure dysregulation, cardiac complications, blood-brain barrier disruption, hemorrhagic stroke transformation, and ischemic penumbra viability. These stroke-related impairments could intensify with inappropriate mobilization/aerobic exercise, hence we deemed the integrity of cerebral autoregulation to be an essential physiological consideration to protect the brain when progressing exercise intensity. Pre-participation screening criteria are proposed and countermeasures to protect the brain from potentially adverse circulatory effects before, during, and following mobilization/exercise sessions are introduced. For example, prolonged periods of standing and static postures before and after mobilization/aerobic exercise may elicit blood pooling and/or trigger coagulation cascades and/or cerebral hypoperfusion. Countermeasures such as avoiding prolonged standing or incorporating periodic lower limb movement to activate the venous muscle pump could counteract blood pooling after an exercise session, minimize activation of the coagulation cascade, and mitigate potential cerebral hypoperfusion. We discuss patient safety in light of the complex nature of stroke presentations (i.e., type, severity, and etiology), medical history, comorbidities such as diabetes, cardiac manifestations, medications, and complications such as anemia and dehydration. The guidelines are easily incorporated into the care model, are low-risk, and use minimal resources. These and other strategies represent opportunities for improving the safety of the activity regimen offered to those in the early phases post-stroke. The timeline for initiating and progressing exercise/mobilization parameters are contingent on recovery stages both from neurobiological and cardiovascular perspectives, which to this point have not been specifically considered in practice. This review includes tailored exercise and mobilization prescription strategies and precautions that are not resource intensive and prioritize safety in stroke recovery.

A Comparison of the Responsiveness of the Postural Assessment Scale for Stroke and the Berg Balance Scale in Patients With Severe Balance Deficits After Stroke

BACKGROUND AND PURPOSE

Previous evidence that the Postural Assessment Scale for Stroke (PASS) and the Berg Balance Scale (BBS) have similar responsiveness is doubtful. Compared with the BBS, the PASS has more items assessing basic balance abilities (such as postural transition during lying and sitting), so it should be more likely to detect changes in patients with severe balance deficits. We aimed to compare the responsiveness of the PASS and the BBS in patients with stroke who have severe balance deficits.

METHODS

The PASS and BBS scores of 49 patients with severe balance deficits at 14 and 30 days after stroke were retrieved. The group-level responsiveness was examined with the standardized response mean (SRM). The individual-level responsiveness was examined by the proportion of patients who achieved clinically significant improvements (ie, their pre-post change scores in the PASS/BBS exceeded the minimal detectable change with 95% confidence of each measure). The responsiveness of the 2 measures was compared using the bootstrap approach.

RESULTS AND DISCUSSION

The comparisons of responsiveness showed significant differences between the PASS and the BBS at both the group and individual levels. At the group level, the PASS indicated moderate changes in balance function (SRM = 0.79), but the BBS indicated only small changes (SRM = 0.39). At the individual level, the PASS showed that 42.9% of patients had clinically significant improvements, while the BBS showed that only 6.1% of patients had clinically significant improvements.

CONCLUSIONS

Compared with the BBS, the PASS was better able to detect balance improvements in patients having severe balance deficits. The PASS is recommended as an outcome measure to detect change in balance in patients with stroke who have severe balance deficits.

A Simple Hospital Mobility Scale for Acute Ischemic Stroke Patients Predicts Long-term Functional Outcome

Background. Stroke patients present restriction of mobility in the acute phase, and the use of a simple and specific scale can be useful to guide rehabilitation. Objective. To validate and propose a Hospital Mobility Scale (HMS) for ischemic stroke patients as well as to evaluate the HMS as a prognostic indicator. Methods. This study was performed in 2 phases: in the first, we developed the HMS content, and in the second, we defined its score and evaluated its psychometric properties. We performed a longitudinal prospective study consisting of 2 cohorts (derivation and validation cohorts). The data were collected in a stroke unit, and the following scales were applied during hospitalization: National Institutes of Health Stroke Scale to quantify stroke severity and the HMS to verify the degree of mobility. The primary outcome was the proportion of unfavorable functional outcomes, defined as a modified Barthel Index of <95. Results. We defined 3 tasks for HMS: sitting, standing, and gait. In the derivation cohort, the HMS presented an accuracy of 84.5% measured using the area under the receiver operating characteristic curve (95% CI = 78.3-90.7; P < .001), whereas in the validation cohort the accuracy was 87.8% (95% CI = 81.9%-93.7%; P < .001). The HMS presented a large standardized effect size (1.41) and excellent interexaminer agreement (intraclass correlation coefficient = 0.962; 95% CI = 0.917-0.983; P < .001). Conclusion. The HMS was able to predict accurately the functional outcome of poststroke patients, presented excellent interexaminer agreement, and was sensitive in detecting changes.

CD200-CD200R1 inhibitory signaling prevents spontaneous bacterial infection and promotes resolution of neuroinflammation and recovery after stroke

BACKGROUND

Ischemic stroke results in a robust inflammatory response within the central nervous system. As the immune-inhibitory CD200-CD200 receptor 1 (CD200R1) signaling axis is a known regulator of immune homeostasis, we hypothesized that it may play a role in post-stroke immune suppression after stroke.

METHODS

In this study, we investigated the role of CD200R1-mediated signaling in stroke using CD200 receptor 1-deficient mice. Mice were subjected to a 60-min middle cerebral artery occlusion and evaluated at days 3 and 7, representing the respective peak and early resolution stages of neuroinflammation in this model of ischemic stroke. Infarct size and behavioral deficits were assessed at both time points. Central and peripheral cellular immune responses were measured using flow cytometry. Bacterial colonization was determined in lung tissue homogenates both after acute stroke and in an LPS model of systemic inflammation.

RESULTS

In wild-type (WT) animals, CD200R1 was expressed on infiltrating monocytes and lymphocytes after stroke but was absent on microglia. Early after ischemia (72 h), CD200R1-knockout (KO) mice had significantly poorer survival rates and an enhanced susceptibility to spontaneous bacterial colonization of the respiratory tract compared to wild-type (WT) controls, despite no difference in infarct or neurological deficits. While the CNS inflammation was resolved by day 7 post-stroke in WT mice, brain-resident microglia and monocyte activation persisted in CD200R1-KO mice, accompanied by a delayed, augmented lymphocyte response. At this time point, CD200R1-KO mice displayed greater weight loss, more severe neurological deficits, and impaired motor function compared to WT. Systemically, CD200R1-KO mice exhibited signs of persistent infection including lymphopenia, T cell activation and memory conversion, and narrowing of the TCR repertoire. These findings were confirmed in a second model of acute neuroinflammation induced by systemic endotoxin challenge.

CONCLUSION

This study defines an essential role of CD200-CD200R1 signaling in stroke. Loss of CD200R1 led to high mortality, increased rates of post-stroke infection, and enhanced entry of peripheral leukocytes into the brain after ischemia, with no increase in infarct size. This suggests that the loss of CD200 receptor leads to enhanced peripheral inflammation that is triggered by brain injury.

Infections Diagnosed after Admission to a Stroke Unit and Their Impact on Hospital Mortality in Poland from 1995 to 2015

BACKGROUND

Implementation of modern stroke unit care might have attenuated the negative effect of infections on stroke outcome. Our aim was to investigate changes in the occurrence of pneumonia and urinary infections diagnosed after admission to experienced Polish stroke center between 1995 and 2015, and their association with hospital mortality.

MATERIALS AND METHODS

This is a retrospective registry-based analysis of consecutive patients with acute stroke from highly urbanized area (Warsaw, Poland) in years 1995-2015. A total of 5174 patients were divided to 4 time periods: 1995-2000 (n = 883), 2001-2006 (n = 1567), 2006-2010 (n = 1539), and 2011-2015 (n = 1183). Odds ratios (ORs) for hospital death were calculated after adjustment for age, congestive heart failure, preexisting disability, stroke type, and baseline neurological deficit, separately in years 1995-2015, 1995-2000, and 2011-2015.

RESULTS

Over time there was a significant decrease in the proportion of patients diagnosed with pneumonia (20%, 19%, 9%, and 15%, respectively) or urinary tract infection (29%, 21%, 24%, and 18%, respectively) and in the proportion of patients having body temperature of 38.0°C or higher at least once within first 7 days of hospital stay (20%, 20%, 13%, and 13%, respectively), without significant change in the use of antibiotics (range 35%-37%). Hospital mortality was strongly predicted by pneumonia (OR 3.6-4.2) and fever (OR 2.7-4.7) but not urinary infections.

CONCLUSIONS

Over the last 2 decades there was a decrease in the proportion of patients with acute stroke diagnosed with pneumonia or urinary tract infection during stroke unit stay. Hospital death was strongly predicted by pneumonia and fever but no by urinary infections.

Thirty-day readmission after spontaneous intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is the most severe form of stroke, but data on readmission after ICH are sparse. We aimed to determine frequency, causes, and predictors of 30-day readmission after ICH.

MATERIALS AND METHODS

This retrospective cohort study includes all spontaneous ICH survivors admitted to the stroke unit at Haukeland University Hospital in Bergen in Norway from July 2007 to December 2013. Patients were followed by review of electronic medical charts, and the first unplanned readmission within 30 days after discharge was used as final outcome. Cox regression analysis was performed to identify predictors of 30-day readmission.

RESULTS

We identified 226 patients with spontaneous ICH, 70 (31.0%) of whom died before discharge or were discharged to palliative care. Of the remaining 156 ICH survivors, 28 (18.0%) were readmitted within 30 days. Median time to readmission was 12 days (IQR 4.5 - 18.5). Most patients were readmitted due to infections (N = 13). None of the patients were readmitted with recurrent stroke. Pneumonia and enteral feeding during the index hospitalization were associated with readmission for infections (both p < .01). Age was the only independent predictor of readmission (HR 1.06, 95% CI 1.02 - 1.11, p = .006).

CONCLUSIONS

Almost one in five of our spontaneous ICH survivors was readmitted within 30 days, and most readmissions were caused by infections.

Risk factors for malnutrition in stroke patients: A meta-analysis

BACKGROUND & AIMS

Stroke is a common cause of death and disability worldwide. Among stroke patients, malnutrition is a significant problem that contributes to poor outcome. Clinical evidence is required to identify risk factors for malnutrition and to adopt appropriate management strategies during early stroke intervention. Thus, we performed a meta-analysis of potential risk factors related to malnutrition in stroke patients.

METHODS

We systemically searched relevant observational studies in MEDLINE, EMBASE, Chinese Biomedical Literature Database (CBLD), China National Knowledge Infrastructure (CNKI), and VIP Database of Chinese periodicals from January 1990 to September 2017 in any language. Patients included in this study were adults who suffered from stroke. Stata 12.0 and Review Manager 5.1 software were used to pool useful data and calculate odds ratios (ORs) and their 95% confidence intervals (CIs). We also performed heterogeneity and sensitivity analyses, and evaluated publication bias.

RESULTS

Twenty-nine observational studies involving 8838 participants who met our inclusion criteria were incorporated into the meta-analysis, and thirteen risk factors related to malnutrition were studied. The following variables probably correlated with an increased risk of malnutrition in stroke patients: malnutrition on admission (OR = 8.34, 95% CI = 4.60-15.10, P < 0.00001), dysphagia (OR = 2.60, 95% CI = 2.24-3.03, P < 0.00001), previous stroke (OR = 3.04, 95% CI = 2.35-3.95, P < 0.00001), diabetes mellitus (OR = 1.79, 95% CI = 1.35-2.38, P < 0.0001), tube feeding (OR = 5.43, 95% CI = 3.99-7.37, P < 0.00001) and reduced level of consciousness (OR = 2.82, 95% CI = 2.12-3.75, P < 0.00001). The factors alcohol consumption, hypertension, male sex, depressed mood, pneumonia and infection need to be re-evaluated. Conversely, smoking was most likely not associated with post-stroke malnutrition.

CONCLUSIONS

Our meta-analysis has revealed a variety of risk factors for malnutrition during hospital stay among stroke patients. Early identification of these factors is warranted for improving patient outcomes.

Noninfectious complications of acute stroke and their impact on hospital mortality in patients admitted to a stroke unit in Warsaw from 1995 to 2015

BACKGROUND

Medical complications often worsen the prognosis after stroke. Our aim was to investigate the association between particular noninfectious complications and hospital mortality of acute stroke patients admitted to an urban Polish stroke center, and changes in their occurrence from 1995 to 2015.

METHODS

This is a retrospective analysis of 5174 consecutive patients admitted for acute ischemic stroke or cerebral hemorrhage to a Polish urban stroke center between 1995 and 2015. The occurrence of complications was reported for years 1995-2000 (n=883), 2001-2006 (n=1567), 2006-2010 (n=1539) and 2011-2015 (n=1183). Odds ratios (OR) with 95% confidence interval (95% CI) for stroke unit death were calculated after adjustment for age, congestive heart failure (CHF), pre-existing disability, stroke type and baseline neurological deficit in three different time periods.

RESULTS

Over time there was a significant decrease in the occurrence of myocardial infarction (MI) (2.2%, 1.4%, 1.0% and 0.3%, respectively), exacerbated CHF (4.6%, 5.1%, 2.6% and 2.0%) and deep vein thrombosis (DVT) (4.6%, 2.7%, 1.2% and 1.1%). Adjusted odds for stroke unit death were increased by myocardial infarction (MI) (OR 17.5, 95% CI: 8.5-35.7), exacerbated CHF (OR 15.0, 95% CI: 9.8-23.0), pulmonary embolism (PE) (OR 11.5, 95% CI: 6.1-21.6), gastrointestinal bleeding (OR 9.2, 95% CI: 4.4-18.9) and recurrent stroke (OR 5.4, 95% CI: 3.1-9.3).

CONCLUSIONS

Over the last two decades Polish urban stroke units may have achieved a significant reduction of the occurrence of some noninfectious complications (i.e. MI, exacerbated CHF and DVT). However, the list of conditions associated with stroke unit mortality includes not only MI and exacerbated CHF but also PE, gastrointestinal bleeding and recurrent stroke.

Management of Acute Stroke in the Older Person

The majority of people who suffer a stroke are older adults. The last two decades have brought major progress in the diagnosis and management of stroke, which has led to significant reductions in mortality, long-term disability, and the need for institutional care. However, acute, interventional and preventative treatments have mostly been trialled in younger age groups. In this article we will provide an overview of the evidence for acute stroke treatments in relation to age, discuss special considerations in the older person, and contemplate patient choice, quality of life, and end-of-life-decisions.