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Sykora M, Krebs S, Miksova D, Badic I, Gattringer T, Fandler-Höfler S, Marko M, Greisenegger S, Knoflach M, Lang W, Ferrari J. IV Thrombolysis vs Early Dual Antiplatelet Therapy in Patients With Mild Noncardioembolic Ischemic Stroke. Neurology 2023; 101:e933-e939. [PMID: 37407270 PMCID: PMC10501095 DOI: 10.1212/wnl.0000000000207538] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/04/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND OBJECTIVES It is unclear whether IV thrombolysis (IVT) outperforms early dual antiplatelet therapy (DAPT) in the acute setting of mild ischemic stroke. The aim of this study was to compare the early safety and efficacy of IVT with that of DAPT. METHODS Data of mild noncardioembolic stroke patients with admission NIH Stroke Scale (NIHSS) score ≤3 who received IVT or early DAPT in the period 2018-2021 were extracted from a nationwide, prospective stroke unit registry. Study endpoints included symptomatic intracerebral hemorrhage (sICH), early neurologic deterioration ≥4 NIHSS points (END), and 3-month functional outcome by modified Rankin scale (mRS). RESULTS A total of 1,195 mild stroke patients treated with IVT and 2,625 patients treated with DAPT were included. IVT patients were younger (68.1 vs 70.8 years), had less hypertension (72.8% vs 83.5%), diabetes (19% vs 28.8%), and a history of myocardial infarction (7.6% vs 9.2%), and slightly higher admission NIHSS scores (median 2 vs median 1) when compared with DAPT patients. After propensity score matching and multivariable adjustment, IVT was associated with sICH (4 [1.2%] vs 0) and END (adjusted odds ratio [aOR] 2.8, 95% CI 1.1-7.5), and there was no difference in mRS 0-1 at 3 months (aOR 1.3, 95% CI 0.7-2.6). DISCUSSION This analysis from a prospective nationwide stroke unit network indicates that IVT is not superior to DAPT in the setting of mild noncardioembolic stroke and may eventually be associated with harm. Further research focusing on acute therapy of mild stroke is highly warranted. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that IVT is not superior to DAPT in patients with acute mild (NIHSS score ≤3) noncardioembolic stroke. The study lacks the statistical precision to exclude clinically important superiority of either therapy.
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Affiliation(s)
- Marek Sykora
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria.
| | - Stefan Krebs
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Dominika Miksova
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Ines Badic
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Thomas Gattringer
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Simon Fandler-Höfler
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Martha Marko
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Stefan Greisenegger
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Michael Knoflach
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Wilfried Lang
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Julia Ferrari
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
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Árokszállási T, Balogh E, Orbán-Kálmándi R, Pásztor M, Árokszállási A, Nagy EB, Belán I, May Z, Csépány T, Csiba L, Bagoly Z, Oláh L. Elevated Blood Alcohol Concentration Is Associated with Improved Clinical Outcomes of Intravenous Thrombolysis Treatment in Acute Ischemic Stroke Patients—A Retrospective Study. J Clin Med 2023; 12:jcm12062238. [PMID: 36983239 PMCID: PMC10051873 DOI: 10.3390/jcm12062238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/04/2023] [Accepted: 03/11/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Intravenous thrombolysis (IVT) improves acute ischemic stroke (AIS) outcomes, but with limited success. In addition, ethanol potentiates the effect of r-tPA in ischemia models. Methods: The effect of acute alcohol consumption on IVT outcomes was investigated in a retrospective cohort study. AIS patients with detectable blood alcohol concentration (BAC) during IVT were included (alcohol group; n = 60). For each case, 3 control subjects who underwent IVT but denied alcohol consumption were matched in terms of age, sex, affected brain area, and stroke severity. Outcomes were determined using the NIHSS at 7 days and the modified Rankin scale (mRS) at 90 days. Results: Patients were younger and had a less severe stroke than in a standard stroke study. Favorable long-term outcomes (mRS 0–2) occurred significantly more frequently in the alcohol group compared to controls (90% vs. 63%, p < 0.001). However, the rates of hemorrhagic transformation were similar. Multiple logistic regression models identified elevated BAC as a significant protective factor against unfavorable short-term (OR: 0.091, 95% CI: 0.036–0.227, p < 0.001) and long-term outcomes (OR: 0.187, 95% CI: 0.066–0.535, p = 0.002). In patients with BAC > 0.2%, significantly lower NIHSS was observed at 3 and 7 days after IVT vs. in those with 0.01–0.2% ethanol levels. Conclusion: Elevated BAC is associated with improved outcomes in IVT-treated AIS without affecting safety.
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Affiliation(s)
- Tamás Árokszállási
- Department of Neurology, Faculty of Medicine, Doctoral School of Neuroscience, University of Debrecen, 22 Móricz Zsigmond krt, H-4032 Debrecen, Hungary
| | - Eszter Balogh
- Department of Neurology, Faculty of Medicine, Doctoral School of Neuroscience, University of Debrecen, 22 Móricz Zsigmond krt, H-4032 Debrecen, Hungary
| | - Rita Orbán-Kálmándi
- Division of Clinical Laboratory Sciences, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 98 Nagyerdei krt, H-4032 Debrecen, Hungary
| | - Máté Pásztor
- Department of Neurology, Medical Centre, Hungarian Defence Forces, 44 Károly Róbert krt, H-1134 Budapest, Hungary
| | - Anita Árokszállási
- Department of Oncology, Faculty of Medicine, University of Debrecen, 98 Nagyerdei krt, H-4032 Debrecen, Hungary
| | - Edit Boglárka Nagy
- Division of Radiology and Imaging Science, Department of Medical Imaging, Faculty of Medicine, University of Debrecen, 98 Nagyerdei krt, H-4032 Debrecen, Hungary
| | - Ivett Belán
- Division of Radiology and Imaging Science, Department of Medical Imaging, Faculty of Medicine, University of Debrecen, 98 Nagyerdei krt, H-4032 Debrecen, Hungary
| | - Zsolt May
- Department of Neurology, Medical Centre, Hungarian Defence Forces, 44 Károly Róbert krt, H-1134 Budapest, Hungary
| | - Tünde Csépány
- Department of Neurology, Faculty of Medicine, Doctoral School of Neuroscience, University of Debrecen, 22 Móricz Zsigmond krt, H-4032 Debrecen, Hungary
| | - László Csiba
- Department of Neurology, Faculty of Medicine, Doctoral School of Neuroscience, University of Debrecen, 22 Móricz Zsigmond krt, H-4032 Debrecen, Hungary
- ELKH-DE Cerebrovascular Research Group, 22 Móricz Zsigmond krt, H-4032 Debrecen, Hungary
| | - Zsuzsa Bagoly
- Division of Clinical Laboratory Sciences, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 98 Nagyerdei krt, H-4032 Debrecen, Hungary
- ELKH-DE Cerebrovascular Research Group, 22 Móricz Zsigmond krt, H-4032 Debrecen, Hungary
| | - László Oláh
- Department of Neurology, Faculty of Medicine, Doctoral School of Neuroscience, University of Debrecen, 22 Móricz Zsigmond krt, H-4032 Debrecen, Hungary
- Correspondence: ; Tel.: +36-52-255-341; Fax: +36-52-255-590
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3
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Yang Y, He Y, Han W, Xu J, Cai Z, Zhao T, Shao Y, Yu M. Clinical factors associated with functional outcomes in patients with single subcortical infarction with neurological deterioration. Front Neurol 2023; 14:1129503. [PMID: 37034074 PMCID: PMC10077891 DOI: 10.3389/fneur.2023.1129503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Objective Factors that predict poor outcomes in patients with single subcortical infarction (SSI) may differ from those that predict poor outcomes in the SSI subgroup with neurological deterioration (ND). This study aimed to investigate the effect of ND on functional outcomes in patients with SSI and the clinical factors that predict poor outcomes in patients with SSI with ND (SSI-ND) and in all patients with SSI. Methods Patients with SSI were consecutively enrolled in this study. ND was defined as an increase of ≥2 points in the National Institutes of Health Stroke Scale (NIHSS) total score, an increase of ≥1 point in the NIHSS subscore of consciousness or motor function, or any new neurological deficit. Results A total of 255 patients were enrolled, and nine (3.53%) were lost to a follow-up. ND [adjusted relative risk (aRR) = 1.37, 95% confidence interval (CI) = 1.22-1.55, p < 0.001], female sex (aRR = 1.13, 95% CI = 1.03-1.24, p = 0.12), initial NIHSS (aRR = 1.08, 95% CI = 1.07-1.10, p < 0.001), and parental arterial disease (PAD) (aRR = 1.16, 95% CI = 1.07-1.26, p = 0.038) were associated with a poor 90-day outcome (the modified Rankin scale (mRS) > 2 points) in patients with SSI. In the SSI-ND subgroup, PAD (aRR = 2.15, 95% CI = 1.20-3.86, p = 0.01), glycosylated hemoglobin (aRR = 1.17, 95% CI = 1.01-1.35, p = 0.035), and severe NIHSS (aRR = 1.15, 95% CI = 1.06-1.25, p = 0.001) were predictive of a poor outcome, and PAD (aRR = 1.87, 95% CI = 1.19-2.95, p = 0.007) was correlated with higher/worsened NIHSS [> 2 points (median)]. For predicting poor outcomes in patients with SSI-ND with PAD, a more severe NIHSS (aRR = 1.09, 95% CI = 1.02-1.17, p = 0.01) was the only determinant, with a cutoff of 4.5 points, a sensitivity of 94.0%, and a specificity of 83.3%. Conclusions ND is an independent predictor of poor outcomes in patients with SSI, and poor outcome determinants in the SSI-ND subgroup and in all patients with SSI are not identical. For patients with SSI-ND, PAD could aggravate ND and was therefore an essential predictor of poor outcomes.
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Affiliation(s)
- Yi Yang
- Department of Neurology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Yue He
- Department of Neurology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Wei Han
- Department of Neurology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - JianHui Xu
- Department of Neurology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - ZhiRong Cai
- Department of Neurology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Tian Zhao
- Department of Radiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - YuanWei Shao
- Department of Radiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Ming Yu
- Department of Neurology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
- *Correspondence: Ming Yu
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4
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Dabhi N, Mastorakos P, Sokolowski JD, Kellogg RT, Park MS. Effect of drug use in the treatment of acute ischemic stroke: A scoping review. Surg Neurol Int 2022; 13:367. [PMID: 36128166 PMCID: PMC9479649 DOI: 10.25259/sni_561_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/27/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Drugs of abuse have been associated with ischemic stroke; however, the clinical presentation, outcomes, and treatment data in this population are limited. The overall safety and efficacy of thrombolytic therapy and thrombectomy in these patients remain unclear. This scoping review summarizes published complications and clinical outcomes in patients with recent abuse of cocaine, methamphetamine (MA), cannabis, decongestant, opioids, alcohol, and 3,4-methylenedioxymethamphetamine (MDMA) presenting with acute ischemic stroke.
Methods:
We conducted a scoping review of the primary literature that assessed outcomes data of thrombolytic therapy or thrombectomy in drug users with acute ischemic stroke. We searched PubMed, Ovid Medline, and Web of Science. Demographic and stroke characteristics, treatment, complications, and clinical outcomes at last follow-up were collected and summarized.
Results:
We identified 51 studies in this review. Drugs of abuse of interest were cocaine (14 studies), MDMA (one study), MA (eight studies), cannabis (23 studies), alcohol (two studies), decongestants (one study), and opioids (two studies). Clinical presentation and stroke presentation were most commonly described features. Thrombectomy outcomes were reported for four patients total (two studies), all with history of cocaine use. Thrombolysis treatment and outcomes were reported for 8851 patients (five studies) with history of cocaine, alcohol, or cannabis. Both treatments were pursued in three patients (three studies). Treatment complications included intracerebral hemorrhage, vasospasm, and cerebral edema.
Conclusion:
Evidence for thrombolytic and thrombectomy treatment in drug users remains limited. Controlled studies are needed to examine complication profile and outcomes following thrombolytic and thrombectomy treatment in this population.
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5
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Fandler-Höfler S, Kneihsl M, Stauber RE, Bisping E, Mangge H, Wünsch G, Haidegger M, Fabisch L, Hatab I, Fickert P, Werring D, Enzinger C, Gattringer T. Liver Fibrosis-4 index indicates atrial fibrillation in acute ischemic stroke. Eur J Neurol 2022; 29:2283-2288. [PMID: 35485970 PMCID: PMC9545754 DOI: 10.1111/ene.15377] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/22/2022] [Indexed: 11/28/2022]
Abstract
Background Non‐alcoholic fatty liver disease and particularly liver fibrosis are related to cardiovascular disease and may indicate an increased risk for atrial fibrillation (AF), but this association has not yet been systematically investigated in a cohort of ischemic stroke patients. Methods We analyzed data from a prospective single‐center study enrolling all consecutive ischemic stroke patients admitted to our stroke unit over a 1‐year period. All patients received a thorough etiological workup. For evaluation of liver fibrosis, we determined the Fibrosis‐4 (FIB‐4) index, a well‐established noninvasive liver fibrosis test. Laboratory results were analyzed from a uniform blood sample taken at stroke unit admission. Results Of 414 included patients (mean age 70.2 years, 57.7% male), FIB‐4 indicated advanced liver fibrosis in 92 (22.2%). AF as the underlying stroke mechanism was present in 28.0% (large vessel disease: 25.6%, small vessel disease: 11.4%, cryptogenic: 29.2%). Patients with FIB‐4 ≥ 2.67 had higher rates of AF (53.3% vs. 20.8%, p < 0.001), and this association remained significant after correction for established AF risk factors (odds ratio 2.53, 95% confidence interval 1.44–4.46, p = 0.001). FIB‐4 was further associated with worse functional outcome 3 months (p < 0.001) and higher mortality 4 years post‐stroke (p < 0.02), but these relationships were no longer present after correction for age and initial stroke severity. Moreover, FIB‐4 was not associated with long‐term recurrent vascular events. Conclusions Liver fibrosis assessed by the FIB‐4 index is independently associated with AF in acute ischemic stroke patients. Further studies should evaluate whether adding the FIB‐4 index to AF risk scores increases their precision.
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Affiliation(s)
| | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Austria
| | - Rudolf E Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Egbert Bisping
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Harald Mangge
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria
| | - Gerit Wünsch
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Austria
| | | | - Linda Fabisch
- Department of Neurology, Medical University of Graz, Austria
| | - Isra Hatab
- Department of Neurology, Medical University of Graz, Austria
| | - Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Austria
| | - David Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Austria.,Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
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Fandler-Höfler S, Stauber RE, Kneihsl M, Wünsch G, Haidegger M, Poltrum B, Pichler A, Deutschmann H, Enzinger C, Fickert P, Gattringer T. Non-invasive markers of liver fibrosis and outcome in large vessel occlusion stroke. Ther Adv Neurol Disord 2021; 14:17562864211037239. [PMID: 34484426 PMCID: PMC8411648 DOI: 10.1177/17562864211037239] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/18/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Liver fibrosis has been identified as an outcome predictor in cardiovascular
disease and has been associated with hematoma expansion and mortality in
patients with primary intracerebral hemorrhage. We aimed to explore whether
clinically inapparent liver fibrosis is related to neurological outcome,
mortality, and intracranial hemorrhage risk in ischemic stroke patients
after mechanical thrombectomy. Methods: We included consecutive patients with anterior circulation large vessel
occlusion stroke treated at our center with mechanical thrombectomy between
January 2011 and April 2019. Clinical data had been collected prospectively;
laboratory data were extracted from our electronic hospital information
system. We calculated the Fibrosis-4 index (FIB-4), an established
non-invasive liver fibrosis test. The main outcomes were postinterventional
intracranial hemorrhage, unfavorable functional status (modified Rankin
scale scores of 3–6), and mortality three months post-stroke. Results: In the 460 patients (mean age 69 years, 49.3% female) analyzed, FIB-4
indicated advanced liver fibrosis in 22.6%. Positive FIB-4 was associated
with unfavorable neurological outcomes and mortality three months
post-stroke, even after correction for co-factors [Odds Ratio (OR) 2.15 for
unfavorable outcome in patients with positive FIB-4, 95% confidence interval
(CI) 1.21–3.83, p = 0.009, and 2.16 for mortality, 95% CI
1.16–4.03, p = 0.01]. However, FIB-4 was neither related to
hemorrhagic transformation nor symptomatic intracranial hemorrhage.
Moreover, atrial fibrillation was more frequent in patients with liver
fibrosis (p < 0.001). Two further commonly-used liver
fibrosis indices (Forns index and the Easy Liver Fibrosis Test) yielded
comparable results regarding outcome and atrial fibrillation. Conclusions: Clinically inapparent liver fibrosis (based on simple clinical and laboratory
parameters) represents an independent risk factor for unfavorable outcomes,
including mortality, at three months after stroke thrombectomy. Elevated
liver fibrosis indices warrant further hepatological work-up and thorough
screening for atrial fibrillation in stroke patients.
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Affiliation(s)
| | - Rudolf E Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Gerit Wünsch
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | | | - Birgit Poltrum
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | | | - Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, Graz, 8036, Austria Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
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7
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Sykora M, Krebs S, Simader F, Gattringer T, Greisenegger S, Ferrari J, Bernegger A, Posekany A, Lang W. Intravenous thrombolysis in stroke with admission NIHSS score 0 or 1. Int J Stroke 2021; 17:109-119. [PMID: 33568019 DOI: 10.1177/1747493021991969] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Up to 30% of stroke patients initially presenting with non-disabling or mild deficits may experience poor functional outcome. Despite, intravenous thrombolysis remains controversial in this subgroup of stroke patients due to its uncertain risk benefit ratio. AIM We aimed to analyze the real-world experience with intravenous thrombolysis in stroke patients presenting with very low NIHSS. METHODS Data of stroke patients presenting with mild initial stroke severity (NIHSS 0-5) including vascular risk factors, stroke syndrome and etiology, early neurological deterioration, symptomatic intracerebral haemorrhage (sICH), and functional outcome by modified Rankin Scale were extracted from a large nationwide stroke registry and analysed. Patients were categorized and compared according to admission severity NIHSS 0-1 versus NIHSS 2-5 and intravenous thrombolysis use. RESULTS Seven hundred and three (2%) of 35,113 patients presenting with NIHSS 0-1 and 6316 (13.9%) of 45,521 of patients presenting with NIHSS 2-5 underwent intravenous thrombolysis. In the NIHSS 0-1 group, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 8.84, CI 6.61-11.83), sICH (adjusted OR 9.32, CI 4.53-19.15) and lower rate of excellent outcome (mRS 0-1) at three months (adjusted OR 0.67, CI 0.5-0.9). In stroke patients with NIHSS 2-5, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 1.7, 1.47-1.98), sICH (adjusted OR 5.75, CI 4.45-7.45), and higher rate of excellent outcome (mRS 0-1) at three months (adjusted OR 1.21, CI 1.08-1.34). CONCLUSIONS Among patients with NIHSS 0-1, intravenous thrombolysis did not increase the likelihood of excellent outcome. Moreover, potential signals of harm were observed. Further research seems to be warranted.
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Affiliation(s)
- Marek Sykora
- Medical Faculty, Sigmund Freud University Vienna, Austria.,Department of Neurology, St John's Hospital, Vienna, Austria
| | - Stefan Krebs
- Department of Neurology, St John's Hospital, Vienna, Austria
| | | | | | | | - Julia Ferrari
- Department of Neurology, St John's Hospital, Vienna, Austria
| | | | - Alexandra Posekany
- Research Unit of Computational Statistics, University of Technology, Vienna
| | - Wilfried Lang
- Medical Faculty, Sigmund Freud University Vienna, Austria.,Department of Neurology, St John's Hospital, Vienna, Austria
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8
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Drieu A, Lanquetin A, Levard D, Glavan M, Campos F, Quenault A, Lemarchand E, Naveau M, Pitel AL, Castillo J, Vivien D, Rubio M. Alcohol exposure-induced neurovascular inflammatory priming impacts ischemic stroke and is linked with brain perivascular macrophages. JCI Insight 2020; 5:129226. [PMID: 31990687 DOI: 10.1172/jci.insight.129226] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 01/15/2020] [Indexed: 02/06/2023] Open
Abstract
Alcohol abuse is a major public health problem worldwide, causing a wide range of preventable morbidity and mortality. In this translational study, we show that heavy drinking (HD) (≥6 standard drinks/day) is independently associated with a worse outcome for ischemic stroke patients. To study the underlying mechanisms of this deleterious effect of HD, we performed an extensive analysis of the brain inflammatory responses of mice chronically exposed or not to 10% alcohol before and after ischemic stroke. Inflammatory responses were analyzed at the parenchymal, perivascular, and vascular levels by using transcriptomic, immunohistochemical, in vivo 2-photon microscopy and molecular MRI analyses. Alcohol-exposed mice show, in the absence of any other insult, a neurovascular inflammatory priming (i.e., an abnormal inflammatory status including an increase in brain perivascular macrophages [PVM]) associated with exacerbated inflammatory responses after a secondary insult (ischemic stroke or LPS challenge). Similar to our clinical data, alcohol-exposed mice showed larger ischemic lesions. We show here that PVM are key players on this aggravating effect of alcohol, since their specific depletion blocks the alcohol-induced aggravation of ischemic lesions. This study opens potentially new therapeutic avenues aiming at blocking alcohol-induced exacerbation of the neurovascular inflammatory responses triggered after ischemic stroke.
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Affiliation(s)
- Antoine Drieu
- INSERM, Physiopathology and Imaging of Neurological Disorders, UMR-S 1237, Normandie Université, Caen, France
| | - Anastasia Lanquetin
- INSERM, Physiopathology and Imaging of Neurological Disorders, UMR-S 1237, Normandie Université, Caen, France
| | - Damien Levard
- INSERM, Physiopathology and Imaging of Neurological Disorders, UMR-S 1237, Normandie Université, Caen, France
| | - Martina Glavan
- INSERM, Physiopathology and Imaging of Neurological Disorders, UMR-S 1237, Normandie Université, Caen, France
| | - Francisco Campos
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Aurélien Quenault
- INSERM, Physiopathology and Imaging of Neurological Disorders, UMR-S 1237, Normandie Université, Caen, France
| | - Eloïse Lemarchand
- INSERM, Physiopathology and Imaging of Neurological Disorders, UMR-S 1237, Normandie Université, Caen, France
| | - Mikaël Naveau
- CNRS, UMR-S 3408, GIP Cyceron, Normandie Université, Caen, France
| | - Anne Lise Pitel
- INSERM, Neuropsychologie et Imagerie de la Mémoire Humaine, UMR-S 1077, Université Paris Sciences et Lettres, Caen, France
| | - José Castillo
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Denis Vivien
- INSERM, Physiopathology and Imaging of Neurological Disorders, UMR-S 1237, Normandie Université, Caen, France
| | - Marina Rubio
- INSERM, Physiopathology and Imaging of Neurological Disorders, UMR-S 1237, Normandie Université, Caen, France
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9
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Hassing LT, Verschoof MA, Koppen H. Alcohol Intoxication as a Stroke Mimic and the Incidence of Acute Alcohol Intoxication in Stroke. J Stroke Cerebrovasc Dis 2019; 28:104424. [PMID: 31624037 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 09/17/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND AIM Alcohol intoxication can be a posterior circulation stroke mimic as they share symptoms such as dysarthria, gait disturbances and nystagmus. We describe alcohol intoxication as a stroke mimic and the frequency of acute alcohol intoxication among stroke patients. METHODS Prospective observational single-center study (2014-2017, Haga Ziekenhuis, the Hague). In all patients older than 16 years presenting as possible acute stroke less than 6 hours of onset, blood ethanol was measured; greater than 0.1 blood alcohol concentration (BAC) was considered elevated. RESULTS In total 974 patients were included: 60 (6%) had elevated blood ethanol (mean: 1.3 BAC). In 180 of 974 patients (18%) a stroke mimic was diagnosed: 12 were due to alcohol intoxication (1% of total cohort, 7% of stroke mimic, mean ethanol level: 2.2 BAC). Half of these patients denied or downplayed their alcohol consumption. Stroke and concurrent alcohol intoxication occurred in 38 of 794 strokes (5%, mean ethanol level: 1.1 BAC). Compared to other stroke patients, these 38 patients presented more often after working hours (mean 6.38pm versus 2.23pm) and received alteplase and endovascular therapy less often (24% versus 43%, P = .018 and 3% versus 10%, P = .241, respectively). CONCLUSIONS Of all patients presenting as possible acute stroke, 6% also drank alcohol. 18% of the whole cohort was diagnosed with a stroke mimic. Acute alcohol intoxication as sole diagnosis was diagnosed in 1% of the total cohort and 7% of stroke mimics, 50% denied or downplayed their alcohol consumption. 5% of all stroke patients also drank alcohol, they were significantly less likely to receive alteplase or endovascular treatment.
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Affiliation(s)
- Laurien T Hassing
- Department of Neurology, Haga Ziekenhuis, The Hague, The Netherlands.
| | | | - Hille Koppen
- Department of Neurology, Haga Ziekenhuis, The Hague, The Netherlands
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10
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Gattringer T, Posekany A, Niederkorn K, Knoflach M, Poltrum B, Mutzenbach S, Haring HP, Ferrari J, Lang W, Willeit J, Kiechl S, Enzinger C, Fazekas F. Predicting Early Mortality of Acute Ischemic Stroke. Stroke 2019; 50:349-356. [DOI: 10.1161/strokeaha.118.022863] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Purpose—
Several risk factors are known to increase mid- and long-term mortality of ischemic stroke patients. Information on predictors of early stroke mortality is scarce but often requested in clinical practice. We therefore aimed to develop a rapidly applicable tool for predicting early mortality at the stroke unit.
Methods—
We used data from the nationwide Austrian Stroke Unit Registry and multivariate regularized logistic regression analysis to identify demographic and clinical variables associated with early (≤7 days poststroke) mortality of patients admitted with ischemic stroke. These variables were then used to develop the Predicting Early Mortality of Ischemic Stroke score that was validated both by bootstrapping and temporal validation.
Results—
In total, 77 653 ischemic stroke patients were included in the analysis (median age: 74 years, 47% women). The mortality rate at the stroke unit was 2% and median stay of deceased patients was 3 days. Age, stroke severity measured by the National Institutes of Health Stroke Scale, prestroke functional disability (modified Rankin Scale >0), preexisting heart disease, diabetes mellitus, posterior circulation stroke syndrome, and nonlacunar stroke cause were associated with mortality and served to build the Predicting Early Mortality of Ischemic Stroke score ranging from 0 to 12 points. The area under the curve of the score was 0.879 (95% CI, 0.871–0.886) in the derivation cohort and 0.884 (95% CI, 0.863–0.905) in the validation sample. Patients with a score ≥10 had a 35% (95% CI, 28%–43%) risk to die within the first days at the stroke unit.
Conclusions—
We developed a simple score to estimate early mortality of ischemic stroke patients treated at a stroke unit. This score could help clinicians in short-term prognostication for management decisions and counseling.
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Affiliation(s)
- Thomas Gattringer
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | - Alexandra Posekany
- Danube University Krems and Gesundheit Österreich GmbH/BIQG, Vienna, Austria (A.P.)
| | - Kurt Niederkorn
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Austria (M.K., J.W., S.K.)
| | - Birgit Poltrum
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | | | - Hans-Peter Haring
- Department of Neurology 1, Kepler Universitätsklinikum, Neuromed Campus, Linz, Austria (H.-P.H.)
| | - Julia Ferrari
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Austria (J.F., W.L.)
| | - Wilfried Lang
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Austria (J.F., W.L.)
| | - Johann Willeit
- Department of Neurology, Medical University of Innsbruck, Austria (M.K., J.W., S.K.)
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Austria (M.K., J.W., S.K.)
| | - Christian Enzinger
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | - Franz Fazekas
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
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11
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Arokszallasi T, Balogh E, Csiba L, Fekete I, Fekete K, Olah L. Acute alcohol intoxication may cause delay in stroke treatment - case reports. BMC Neurol 2019; 19:14. [PMID: 30696413 PMCID: PMC6350361 DOI: 10.1186/s12883-019-1241-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/16/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The signs and symptoms of acute alcohol intoxication resemble those of vertebrobasilar stroke. Due to their shared symptoms including double vision, nystagmus, dysarthria, and ataxia, the differential diagnosis of alcohol intoxication and vertebrobasilar stroke may pose a challenge. Moreover, if alcohol intoxication and stroke occur simultaneously, the signs and symptoms of stroke may be attributed to the effects of alcohol, leading to delayed stroke diagnosis and failure to perform reperfusion therapy. CASE PRESENTATIONS Three cases of alcohol intoxication and stroke are presented. The first patient (female, 50 years old) had dysarthria, nystagmus and trunk ataxia on admission. Her blood alcohol level was 2.3‰. The symptoms improved after forced diuresis, but 5.5 h later progression was observed, and the patient developed diplopia and dysphagia in addition to her initial symptoms. Angiography showed occlusion of the basilar artery. Intraarterial thrombolysis was performed. The second patient (male, 62 years old) developed diplopia, dysarthria and trunk ataxia after consuming 4-units of alcohol, and his symptoms were attributed to alcohol intoxication. Two hours later, neurological examination revealed dysphagia and mild right-sided hemiparesis, which questioned the causal relationship between the symptoms and alcohol consumption. Cerebral CT was negative, and intravenous thrombolysis was administered. The third patient (male, 55 years old) consumed 10 units of alcohol before falling asleep. Three hours later, his relatives tried to wake him up. He was unresponsive, which was attributed to alcohol intoxication. When he woke up 8 h later, right-sided hemiparesis and aphasia were observed, and cerebral CT already revealed irreversible ischemic changes. CONCLUSIONS Our cases show that alcohol consumption may interfere with stroke diagnosis by mimicking the signs and symptoms of vertebrobasilar stroke. Moreover, attributing the symptoms of stroke to alcohol intoxication may delay stroke diagnosis resulting in failure of reperfusion therapy. Based on our observations we conclude that stroke should be considered in the case of worsening symptoms, dysphagia, hemiparesis and disproportionately severe signs that cannot be attributed to the amount of alcohol consumed. In the case of ambiguity, ambulance should be called, and if stroke cannot be excluded, specific therapy should be administered.
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Affiliation(s)
- Tamas Arokszallasi
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary.
| | - Eszter Balogh
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary
| | - Laszlo Csiba
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary.,Cerebrovascular and Neurodegenerative Research Group of the Hungarian Academy of Sciences, Moricz Zs. krt 22, Debrecen, 4032, Hungary
| | - Istvan Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary
| | - Klara Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary
| | - Laszlo Olah
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary
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