Short-term and long-term stroke survival: the belgrade prognostic study

Predictions for functional outcome and mortality in acute ischaemic stroke following successful endovascular thrombectomy

Background

Accurate outcome predictions for patients who had ischaemic stroke with successful reperfusion after endovascular thrombectomy (EVT) may improve patient treatment and care. Our study developed prediction models for key clinical outcomes in patients with successful reperfusion following EVT in an Australian population.

Methods

The study included all patients who had ischaemic stroke with occlusion in the proximal anterior cerebral circulation and successful reperfusion post-EVT over a 7-year period. Multivariable logistic regression and Cox regression models, incorporating bootstrap and multiple imputation techniques, were used to identify predictors and develop models for key clinical outcomes: 3-month poor functional status; 30-day, 1-year and 3-year mortality; survival time.

Results

A total of 978 patients were included in the analyses. Predictors associated with one or more poor outcomes include: older age (ORs for every 5-year increase: 1.22-1.40), higher premorbid functional modified Rankin Scale (ORs: 1.31-1.75), higher baseline National Institutes of Health Stroke Scale (ORs: 1.05-1.07) score, higher blood glucose (ORs: 1.08-1.19), larger core volume (ORs for every 10 mL increase: 1.10-1.22), pre-EVT thrombolytic therapy (ORs: 0.44-0.56), history of heart failure (outcome: 30-day mortality, OR=1.87), interhospital transfer (ORs: 1.42 to 1.53), non-rural/regional stroke onset (outcome: functional dependency, OR=0.64), longer onset-to-groin puncture time (outcome: 3-year mortality, OR=1.08) and atherosclerosis-caused stroke (outcome: functional dependency, OR=1.68). The models using these predictors demonstrated moderate predictive abilities (area under the receiver operating characteristic curve range: 0.752-0.796).

Conclusion

Our models using real-world predictors assessed at hospital admission showed satisfactory performance in predicting poor functional outcomes and short-term and long-term mortality for patients with successful reperfusion following EVT. These can be used to inform EVT treatment provision and consent.

Heterogeneity in the diagnosis and prognosis of ischemic stroke subtypes: 9-year follow-up of 22,000 cases in Chinese adults

BACKGROUND

Reliable classification of ischemic stroke (IS) etiological subtypes is required in research and clinical practice, but the predictive properties of these subtypes in population studies with incomplete investigations are poorly understood.

AIMS

To compare the prognosis of etiologically classified IS subtypes and use machine learning (ML) to classify incompletely investigated IS cases.

METHODS

In a 9-year follow-up of a prospective study of 512,726 Chinese adults, 22,216 incident IS cases, confirmed by clinical adjudication of medical records, were assigned subtypes using a modified Causative Classification System for Ischemic Stroke (CCS) (large artery atherosclerosis (LAA), small artery occlusion (SAO), cardioaortic embolism (CE), or undetermined etiology) and classified by CCS as "evident," "probable," or "possible" IS cases. For incompletely investigated IS cases where CCS yielded an undetermined etiology, an ML model was developed to predict IS subtypes from baseline risk factors and screening for cardioaortic sources of embolism. The 5-year risks of subsequent stroke and all-cause mortality (measured using cumulative incidence functions and 1 minus Kaplan-Meier estimates, respectively) for the ML-predicted IS subtypes were compared with etiologically classified IS subtypes.

RESULTS

Among 7443 IS subtypes with evident or probable etiology, 66% had SAO, 32% had LAA, and 2% had CE, but proportions of SAO-to-LAA cases varied by regions in China. CE had the highest rates of subsequent stroke and mortality (43.5% and 40.7%), followed by LAA (43.2% and 17.4%) and SAO (38.1% and 11.1%), respectively. ML provided classifications for cases with undetermined etiology and incomplete clinical data (24% of all IS cases; n = 5276), with area under the curves (AUC) of 0.99 (0.99-1.00) for CE, 0.67 (0.64-0.70) for LAA, and 0.70 (0.67-0.73) for SAO for unseen cases. ML-predicted IS subtypes yielded comparable subsequent stroke and all-cause mortality rates to the etiologically classified IS subtypes.

CONCLUSION

This study highlighted substantial heterogeneity in prognosis of IS subtypes and utility of ML approaches for classification of IS cases with incomplete clinical investigations.

Persistent or permanent atrial fibrillation is associated with severe cardioembolic stroke in patients with non-valvular atrial fibrillation

BACKGROUND

Little is known about the difference in the severity of cardioembolic (CE) stroke between patients with paroxysmal atrial fibrillation (PAF) and persistent/permanent AF (PerAF). We assessed stroke severity in patients with CE stroke divided by the type of AF.

METHODS

Three hundred and fifty-eight consecutive patients with CE stroke within 48 h of onset and with a modified Rankin Scale (mRS) score ≤ 1 before onset were studied. We compared basic characteristics, stroke severity, and functional outcome between patients with PAF (n = 127) and PerAF (n = 231).

RESULTS

Patients with PerAF were more likely to take oral anticoagulants (OACs) than those with PAF (37% vs. 13%, P <  0.0001), even though still underuse of OAC in both patients. Regarding stroke severity on admission, patients with PerAF exhibited a tendency toward a higher score on the National Institutes of Health Stroke Scale (NIHSS) compared with patients with PAF (12 [5-20] vs. 9 [4-18]; P = 0.12). Mortality and mRS score at discharge were higher in the PerAF than in the PAF group (13% vs. 4%; P = 0.005, and 3 [1-5] vs. 2 [1-4]; P = 0.01, respectively). Multivariate analyses confirmed that PerAF was a significant determinant of severe stroke (NIHSS score > 8) on admission (odds ratio [OR] to PAF = 1.80; 95% confidence interval [CI] 1.08-2.98; P = 0.02) and of an mRS score ≥ 3 at discharge (OR = 2.07; 95% CI 1.24-3.46; P = 0.006). Patients with PerAF had three times more internal carotid artery occlusion evaluated by magnetic resonance angiography, which indicated a more severe cerebral embolism compared with patients with PAF.

CONCLUSIONS

We found underuse of OAC in high risk AF patients with CE stroke. PerAF is significantly associated with severe stroke on admission and an unfavorable functional outcome at discharge in Japanese patients with CE stroke.

Early Prediction of One-Year Mortality in Ischemic and Haemorrhagic Stroke

BACKGROUND

In Denmark 15%-20% of stroke victims die within the first year. Simple and valid tools are needed to assess patients' risk of dying. The aim of this study was to identify potential predictors of 1-year mortality in stroke victims and construct a simple and valid prediction model.

METHODS

Data were collected retrospectively from a cohort of 1031 stroke victims admitted over a period of 18 months at Nordsjællands Hospital, Denmark. Follow-up was 1 year after symptom onset. Multiple logistic regression analysis with backwards selection was used to identify predictors and construction of a prediction model. The model was validated using cross validation with 10,000 repeated random splits of the dataset. Area under the receiver operating characteristic curve (AUC) and Brier score were used as measures of validity.

RESULTS

Within the first year 186 patients died (18.0%) and 4 (0.4%) were lost to follow-up. Age (OR 1.08), gender (OR 2.19), stroke severity (OR 1.03), Early Warning Score (OR 1.17), Performance Status (ECOG) (OR 1.94), Body Mass Index (OR 0.91), the Charlton's Comorbidity Index (OR 1.17), and urinary problems (OR 2.55) were found to be independent predictors of 1-year mortality. A model including age, stroke severity, Early Warning Score, and Performance Status was found to be valid (AUC 86.5 %, Brier Score 9.03).

CONCLUSIONS

A model including only 4 clinical variables available shortly after admission was able to predict the 1-year mortality risk of patients with acute ischemic and haemorrhagic stroke.

Cardiac wall motion abnormality as a predictor for undetermined stroke with embolic lesion-pattern

OBJECTIVES

Several strokes of potential embolism do not clearly meet the definitions of embolic stroke with unknown source, cryptogenic stroke, or cardioembolic (CE) stroke. Considering the high mortality and recurrence of CE strokes, it is very important to detect treatable cardiac sources of embolism. Although regional wall motion abnormality (RWMA) of the left ventricle (LV) seems to be related to CE stroke, association between cerebral embolic risk and RWMA remains unclear. The purpose of this study was to investigate the influence of RWMA on undetermined stroke with embolic lesion-pattern (USELP).

PATIENTS AND METHODS

Among a total of 2327 patients with acute ischemic stroke, we excluded 148 patients without a transthoracic echocardiography (TTE). According to a stepwise approach, we excluded patients without an embolic lesion-pattern. Finally, we divided patients into two groups (USELP, 119, and non-embolic stroke, 1237). We classified patients' RWMAs into three major arterial territories according to the standard 17-segment model of TTE.

RESULTS

Among the included 1356 patients, those with USELP had larger internal dimension at diastole and systole in LV, reduced LV ejection fraction, increased E/A ratios, mitral valve disease, and RWMA. After adjusting for multiple variables, binary logistic regression revealed that RWMA was significantly associated with USELP (OR 7.02, 95 % CI: 3.51-14.01, p<0.001).

CONCLUSION

This study provides significant information to support that RWMA can be a predictor for undetermined embolic stroke. In this regard, RWMA were highly correlated with patients whose imaging supported an embolic source compared to those without this radiographic pattern.

Trends in cerebrovascular diseases mortality in Serbia, 1997-2016: a nationwide descriptive study

OBJECTIVES

Over the last decades, mortality from cerebrovascular diseases (CVDs) has decreased in many countries. The aim of this study was to assess the trends of CVDs mortality in Serbia.

METHODS

Descriptive epidemiological study. Age-standardised rates (ASRs) for CVDs mortality were assessed by joinpoint regression analysis to identify significant changes in trends and estimate annual per cent changes with 95% CI. The age-period-cohort analysis has been used to describe variations in mortality.

RESULTS

Over this 20-year period, there were 312 847 deaths from CVDs, with the overall average annual ASR of 148.4 per 100 000. The trend of ASRs from CVDs mortality in males in Serbia showed a significant joinpoint: rates insignificantly decreased from 1997 to 2005 by -0.8% per year (95% CI -1.7% to 0.2%) and thereafter rapidly decreased by -5.0% per year (95% CI -5.6% to -4.5%). A joinpoint for females was found in 2006: the mortality trend was first significantly decreasing by -1.0% per year (95% CI -1.9% to -0.0%) and then sharply falling down by -6.0% per year (95% CI -6.8% to -5.3%). Results of age-period-cohort analysis indicated that the relative risk for CVDs mortality showed statistically significant (p<0.05) cohort and period effects, as well as the net drift and local drifts in Serbian population. The trends in mortality for all subtypes of CVDs were similar in both sexes: trends significantly decreased for most subtypes, with the exception of a significant increase for cerebral infarction.

CONCLUSIONS

After a decade of increase, CVDs mortality rates are declining in last decade in Serbia. However, mortality rates from CVDs remain exceedingly high in Serbia. Differences in mortality trends of the stroke subtypes should be taken into account in the creation of both prevention and treatment guidelines.

Short-term and long-term survival probabilities among first-ever ischaemic and haemorrhagic stroke patients at a hospital in the suburban east coast of Peninsular Malaysia

AIM

This study aimed to determine the 28-day, 1-year, and 5-year survival probabilities in first-ever stroke patients in a relatively understudied setting: a suburban hospital that serves a predominantly rural population in the east coast of Peninsular Malaysia.

METHODS AND RESULTS

A retrospective record review was conducted among 432 first-ever stroke patients admitted to the Hospital Universiti Sains Malaysia, Kelantan, Malaysia. Data from between January 1, 2005 and December 31, 2011, were extracted from the medical records. The Kaplan-Meier product limit estimator was applied to determine the 28-day, 1-year, and 5-year survival probabilities. Log-rank test was used to test the equality of survival time between different groups. A total of 101 patients died during the study period. The 28-day, 1-year, and 5-year survival probabilities were 78.0% (95% confidence interval [CI]: 73.5-81.9), 74.2% (95% CI: 69.4-78.4), and 70.9% (95% CI: 65.1-75.9), respectively. There were significant differences in the survival time based on the types of stroke, Glasgow Coma Scale, hyperlipidaemia, atrial fibrillation, fasting blood glucose, and diastolic blood pressure.

CONCLUSION

This study, though retrospective, highlights several clinical parameters that influenced the survival probabilities among first-ever stroke patients managed in a suburban setting in Malaysia, and compared them to those reported in more urban regions. Our data emphasise the need for wider establishment of specialized stroke units and teams, as well as for prospective multi-centre studies on first-ever stroke patients to better inform the development of stroke care provision in Malaysia.

The influence of dehydration on the prognosis of acute ischemic stroke for patients treated with tissue plasminogen activator

Background

Many studies have determined that dehydration is an independent predictor of outcome after ischemic stroke (IS); however, none have determined if the use of thrombolytic therapy modifies the negative impact of poor hydration. To inform the stroke registry established at our institution, we conducted a retrospective study to determine if dehydration remains a negative prognostic factor after IS patients treated with tissue plasminogen activator (tPA).

Methods

Between 2007 and 2012, we recruited 382 subjects; 346 had data available and were divided into 2 groups on the basis of their blood urea nitrogen/creatinine (BUN/Cr) ratio. Dehydrated subjects had a BUN/Cr ratio ≥ 15; hydrated subjects had a BUN/Cr < 15. The primary outcome was impairment at discharge as graded by the Barthel Index (BI) and the modified Rankin Scale (mRS).

Results

The dehydration group had a greater mean age; more women; lower mean levels of hemoglobin, triglycerides, and sodium; and higher mean potassium and glucose levels. A favorable outcome as assessed by the mRS (≤2) was significantly less frequent among dehydrated subjects, but a favorable outcome by the BI (≥60) was not. Logistic regression and multivariate models confirmed that dehydration is an independent predictor of poor outcome by both the mRS and the BI; however, it was not predictive when patients were stratified by Trial of Org 10,172 in Acute Stroke Treatment subtype.

Conclusions

Our findings indicate that use of thrombolytic therapy does not eliminate the need to closely monitor hydration status in patients with IS.

Factors Related to Cardioembolism as Major Predictors of Poor Survival after First-Ever Middle Cerebral Artery Stroke Treated with Thrombolysis

<b><i>Background and Purpose:</i></b> Prognostic factors related to mortality rates after stroke have been reported; however, most studies included different treatments and did not focus solely on ischemic stroke. The study aimed to report the short- and long-term survival and predictors of death in patients with first-ever ischemic stroke in the middle cerebral artery (MCA) territory, submitted to intravenous thrombolysis (IVT). <b><i>Methods:</i></b> A prospective observational cohort study of patients with first-ever ischemic stroke in the MCA territory treated with IVT from March 2010 to February 2015 was conducted, and patients were followed up until May 2015. The Kaplan-Meier method was used to estimate the cumulative case fatality rates. The potential prognostic factors were identified using Cox proportional hazards regression analysis. <b><i>Results:</i></b> A total of 169 patients, 51% women of mean age of 64.1 ± 12.9 years were followed up for a median time of 23.6 (8.1-36.2) months. At the end of the study, 53 (31.4%) patients had died. The estimated cumulative case fatality rate was 41.8% for 5 years. Chronic heart failure (hazards ratio [HR] 2.89, 95% CI 1.43-5.84, <i>p</i> = 0.003), atrial fibrillation (HR 3.88, 95% CI 1.30-11.57, <i>p</i> = 0.015), and symptomatic intracerebral hemorrhage (SICH; HR 7.83, 95% CI 3.43-17.92, <i>p</i> < 0.001) were significant unfavorable independent outcome predictors. The most frequent cause of death was infection (46%). <b><i>Conclusions:</i></b> Stroke in the MCA territory has a high mortality rate, even in patients treated with IVT. SICH, atrial fibrillation, and chronic heart failure are modifiable factors related to cardioembolism that need to be aggressively targeted for improved outcomes after stroke.

The Epidemiology of Atrial Fibrillation and Stroke

The burden of stroke is increasing due to aging population and unhealthy lifestyle habits. The considerable rise in atrial fibrillation (AF) is due to greater diffusion of risk factors and screening programs. The link between AF and ischemic stroke is strong. The subtype most commonly associated with AF is cardioembolic stroke, which is particularly severe and shows the highest rates of mortality and permanent disability. A trend toward a higher prevalence of cardioembolic stroke in high-income countries is probably due to the greater diffusion of AF and the control of atherosclerotic of risk factors.

Case fatality rate ‎and disability of stroke in Isfahan, Iran: Isfahan stroke registry

BACKGROUND

Few investigators have reported case fatality and disability of Iranian patients with stroke. This study was designed to collect morbidity and case fatality data of hospitalized patients with stroke, and stroke care quality in Isfahan, Iran.

METHODS

From 2006 to 2011, from overlapping sources (discharge diagnoses, attending physicians, and hospitalization wards), all hospitalized patients with possible strokes were enrolled in the study, their hospital records were summarized by experienced personnel and reviewed by a neurologist with stroke experience. Patients were followed by phone calls or visited to their addresses and their 28(th) day functional status was checked by translated modified Rankin Scale (mRS). Forms and methods were derived from the World Health Organization (WHO) Monitoring Trends and Determinants in Cardiovascular Disease and STEPS projects.

RESULTS

A total of 9487 patients were identified to suffer from stroke. Their ages' mean was 68.98 ± 13.63 years, and 50.0% were females. In hospital, case fatality was 16.5% and the 28(th) day case fatality was 25.6%. The greatest case fatality was among intracerebral hemorrhage (ICH) patients and the least among ischemic stroke (IS) ones. Case fatality was greater among female and older patients and those with the previous history of stroke. Among survivors, only 26.9% were functionally independent (mRS < 3) which was the greatest among subarachnoid hemorrhage (SAH) patients and least among ICH patients. None of the patients were admitted to specific stroke units or received thrombolytic therapy.

CONCLUSION

The hospitalized patients with stroke in Isfahan have unfavorable outcome compared with their mates in developed countries. A low quality of stroke care may be responsible, and urgent attention is needed.

Analysis of the risk factors for the short-term prognosis of acute ischemic stroke

This study investigated the risk factors for the short-term prognosis of acute ischemic stroke to provide a scientific evidence for improving prevention and treatment. A total of 2557 cases of acute ischemic stroke were included in the study. We collected the data on demographic characteristics, life style-related risk factors, clinical feature, and other clinical characteristics for all the participants. The outcomes were assessed using the modified Rankin scale (mRs) on day 14 or at discharge. According to the mRs score, the subjects were divided into three groups, namely, the control group (0≤ mRs ≤2), the disability group (3≤ mRs ≤5), and the death group (mRs = 6). The general conditions of these three groups were compared. An mRs score of 3≤ mRs ≤6 belonged to the composite outcome group. Logistic regression was also applied to analyze the risk factors of short-term prognosis. Monovariant logistic regression showed that age, on-set admission, hospital stays, temperature, heart rate, stroke subtype, hypertension, hyperglycemia, history of heart disease, history of atrial fibrillation, history of cerebral stroke, drinking, count of WBC, count of mononuclear leucocyte, and rate of neutrophile granulocyte were statically significant. To further control the confounding factors, multivariant logistic regression analysis was carried out. The result showed that age, on-set admission, hospital stays, temperature, heart rate, hyperglycemia, history of atrial fibrillation, and cerebral stroke history were related to the short-term prognosis. Age, on-set admission, hospital stays, temperature, heart rate, hyperglycemia, history of atrial fibrillation, and cerebral stroke history were the risk factors of the short-term prognosis of acute ischemic stroke.