Wytyczne postępowania w udarze mózgu

The Absence of Typical Stroke Symptoms and Risk Factors Represents the Greatest Risk of an Incorrect Diagnosis in Stroke Patients

BACKGROUND

Stroke is one of the most misdiagnosed conditions that causes serious medical disabilities. Its early and accurate diagnosis by the emergency team is crucial for the patient's survival. This study aimed to determine the percentage of brain strokes incorrectly diagnosed by paramedic teams and to analyze the factors influencing incorrect diagnoses.

METHODS

The data of 103 patients, mean age of 68.4 ± 14.96 years, admitted in 2019 to hospital emergency departments of the two hospitals in Olsztyn, Poland, were analyzed retrospectively. All patient data were obtained from their information cards. The parameters of the patients misdiagnosed and accurately diagnosed by paramedics were analyzed with Odds Ratio (OR) calculations using IBM SPSS version 23 software.

RESULTS

Stroke and transient ischemic attack were recognized in 77 cases (74.8%). In 26 patients (25.2%), the diagnosis made in the ambulance differed from that made in the hospital ward. The analysis of the Odds Ratio (OR) has shown that typical stroke risk factors, if present in a patient, facilitate the correct diagnosis. The greatest source of misdiagnosis of stroke by the paramedic team was the lack of hemiplegia (OR = 6.0).

CONCLUSIONS

The absence of typical stroke risk factors and neurological stroke symptoms, such as smoking, hemiplegia, aphasia, hypercholesterolemia, arrhythmia, diabetes or a drooping corner of the mouth, constitutes a high risk of misdiagnosing stroke by the paramedic team.

Study of the Possibility of Using Virtual Reality Application in Rehabilitation among Elderly Post-Stroke Patients

Thanks to medical advances, life expectancy is increasing. With it comes an increased incidence of diseases, of which age is a risk factor. Stroke is among these diseases, and is one of the causes of long-term disability. The opportunity to treat these patients is via rehabilitation. A promising new technology that can enhance rehabilitation is virtual reality (VR). However, this technology is not widely used by elderly patients, and, moreover, the elderly often do not use modern technology at all. It therefore becomes a legitimate question whether elderly people will be able to use virtual reality in rehabilitation. This article presents a rehabilitation application dedicated to patients with upper limb paresis and unilateral spatial neglect (USN). The application was tested on a group of 60 individuals including 30 post-stroke patients with an average age of 72.83 years. The results of the conducted study include a self-assessment by the patients, the physiotherapist's evaluation, as well as the patients' performance of the exercise in VR. The study showed that elderly post-stroke patients are able to use virtual reality applications, but the ability to correctly and fully perform an exercise in VR depends on several factors. One of them is the ability to make logical contact (p = 0.0001 < 0.05). However, the study presented here shows that the ability to use VR applications does not depend on age but on mental and physical condition, which gives hope that virtual reality applications can be used in post-stroke rehabilitation among patients of all ages.

Non-compliance with medical recommendations results in delayed hospitalization and poorer prognosis in patients with cerebral ischemic stroke in Poland: Non-compliance effects on post-ischemic stroke prognosis

OBJECTIVES

This study aimed to reveal and analyze the causes of delays in reaching the hospital of patients with cerebral ischemic stroke and to assess their clinical picture.

MATERIAL AND METHODS

The study group included 161 patients with stroke, who reported to the hospital beyond the thrombolytic treatment therapeutic window. The control group consisted of 85 patients recruited consecutively with stroke who received thrombolytic treatment per eligibility criteria. Laboratory and medical imaging tests essential for neurological condition assessment were conducted in the study group. Control group research was based on retrospective analysis of medical records.

RESULTS

The rate of deaths during hospitalization was lower in the control group (4.7%) compared to the study group (14.9%). In the study group, more patients (16.8%) admitted to non-compliance with medical recommendations than in the control group (5.9%). There were no statistically significant differences in nicotinism and alcohol dependence syndrome frequency between both groups.

CONCLUSIONS

Based on each group inclusion criteria, a lower mortality rate in the control group indicates a crucial role of the therapeutic window in cerebral stroke treatment. Analysis of reasons for delay points out that efficient prophylaxis is the education of patients with stroke risk factors and their families.

High neutrophil-to-lymphocyte ratio (NLR) predicts poor response to intravenous thrombolysis in white Caucasian stroke patients

OBJECTIVES

Our aim was to investigate usefulness of the neutrophil-to-lymphocyte ratio (NLR) for predicting poor response to intravenous rtPA in white Caucasian ischemic stroke patients treated within 4.5 hours from the onset.

MATERIALS AND METHODS

This retrospective analysis included all consecutive acute ischemic stroke patients (N = 344) treated with rtPA in a tertiary stroke center from 2011 to 2017. NLR was calculated from complete blood counts obtained on admission. The patients were classified into NLR terciles (T1 <1.75, T2<2.97, T3≥2.97). Significant neurological improvement was defined as an 8-point reduction in the NIHSS score or reaching the score of 0 to 1.

RESULTS

Compared to NLR T1, patients from NLR T3 were significantly older, more often disabled before stroke, and had longer onset-to-needle time. They less often achieved neurological improvement at day 7 (38% vs 59% p=0.002) and had higher 90-day mortality (27% vs 13%, p=0.020), with no differences in neurological improvement at 24 hours, occurrence of sICH and 7-day mortality. Each additional 4 units of NLR decreased unadjusted and adjusted odds for achieving favorable outcome at day 7 (OR 0.65, 95% CI: 0.46-0.92; aOR 0.62, 95% CI: 0.39-1.00), and increased the odds for death at 3 months (OR 1.60, 95% CI: 1.15-2.24; aOR 1.82, 95% CI:1.14-2.92) CONCLUSIONS: High NLR can predict poor response to intravenous rtPA in Caucasian patients with acute ischemic stroke, especially in terms of not achieving significant neurological improvement at day 7 and death at day 90. It encourages attempts to incorporate NLR in already validated scores.

Statins and 90-Day Functional Performance and Survival in Patients with Spontaneous Intracerebral Hemorrhage

BACKGROUND

The neuroprotective effect of statins has become a focus of interest in spontaneous intracerebral hemorrhage (sICH). The purpose of this study was: (1) to evaluate the effect of statin use by the analyzed patients with sICH in the period preceding the onset of hemorrhage on their baseline neurological status and baseline neuroimaging of the head; (2) to evaluate the effect of statin use in the acute period of hemorrhage on the course and prognosis in the in-hospital period, taking into account whether the statin was taken before the hemorrhage or only after its onset; (3) to evaluate the effect of continuing statin treatment after in-hospital treatment on the functional performance and survival of patients up to 90 days after the onset of sICH symptoms, taking into account whether the statin was taken before the onset of sICH.

MATERIAL AND METHODS

A total of 153 patients diagnosed with sICH were analyzed, where group I were not previously taking a statin and group II were taking a statin before sICH onset. After lipidogram assessment, group I was divided into patients without dyslipidemia and without statin treatment (Ia) and patients with dyslipidemia who received de novo statin treatment during hospitalization (Ib). Group II patients continued taking statin therapy. We evaluated the effect of prior statin use on the severity of hemorrhage; the effect of statin use during the acute period of sICH on its in-hospital course; and the effect of statin treatment on the severity of neurological deficit, functional capacity and survival of patients up to 90 days after the onset of sICH symptoms.

RESULTS

There was no effect of prior statin use on the severity of hemorrhage as assessed clinically and by neuroimaging of the head. At in-hospital follow-up, subgroup Ia was the least favorable in terms of National Institutes of Health Stroke Scale (NIHSS) score. This subgroup had the highest percentage of deaths during hospitalization. In the post-hospital period, the greatest number of patients with improvement in the NIHSS, modified Rankin Scale (mRS) and Barthel scales were among those taking statins, especially group II patients. At 90-day follow-up, survival analysis fell significantly in favor of subgroup Ib and group II.

CONCLUSIONS

1. The use of statins in the pre-sICH period did not adversely affect the patients' baseline neurological status or the results of baseline neuroimaging studies. 2. Continued statin therapy prior to the onset of sICH or the inclusion of statins in acute treatment in patients with sICH and dyslipidemia does not worsen the course of the disease and the in-hospital prognosis. Statin therapy should not be discontinued during the acute phase of sICH. 3. To conclude the eventual beneficial effect on the functional performance and survival of patients after sICH onset, comparability of the analyzed groups in terms of clinical, radiological and other prognostic factors in spontaneous intracerebral hemorrhage would be needed. Future studies are needed to confirm these findings.

Thrombectomy-Capable Stroke Centre-A Key to Acute Stroke Care System Improvement? Retrospective Analysis of Safety and Efficacy of Endovascular Treatment in Cardiac Cathlab

The optimal structure of the acute ischaemic stroke treatment network is unknown and eagerly sought. To make it most effective, different treatment and transportation strategies have been developed and investigated worldwide. Since only a fraction of acute stroke patients with large vessel occlusion are treated, a new entity-thrombectomy-capable stroke centre (TCSC)-was introduced to respond to the growing demand for timely endovascular treatment. The purpose of this study was to present the early experience of the first 70 patients treated by mechanical means in a newly developed cardiac Cathlab-based TCSC. The essential safety and efficacy measures were recorded and compared with those reported in the invasive arm of the HERMES meta-analysis-the largest published dataset on the subject. We found no significant differences in terms of clinical and safety outcomes, such as early neurological recovery, level of functional independence at 90 days, symptomatic intracranial haemorrhage, parenchymal haematoma type 2, and mortality. These encouraging results obtained in the small endovascular centre may be an argument for the introduction of the TCSC into operating stroke networks to increase patient access to timely treatment and to improve clinical outcomes.

Reliability of the modified Rankin Scale in clinical practice of stroke units and rehabilitation wards

Introduction

The Modified Rankin Scale (mRS) is the most common tool to quantify post-stroke disability in everyday practice and by certified raters in clinical trials. However, interobserver variability may affect reliability of retrospective observational studies, including clinical registries. Our aim was to assess real-life consistency between neurologists and physical and rehabilitation medicine physicians using mRS to rate post-stroke disability of patients transferred directly from stroke unit (SU) to rehabilitation ward (RW).

Methods

This is a retrospective analysis of 132 consecutive acute stroke patients transferred from single tertiary SU to RW located in the same hospital in Poland. Patients were assessed by one rater from each department at the day of transfer. We distinguished between physicians previously certified in using mRS for clinical trials and not-certified physicians using mRS in everyday practice.

Results

mRS at discharge from SU and on admission to RW was recorded for 105 of 132 patients. The overall agreement was 70.5% (kappa 0.55). Similar agreement was observed in the subset of 30 patients rated by certified physicians in both departments (70.0%, kappa 0.57) and in the subset of 61 patients rated by a pair of certified neurologist and not-certified rehabilitation physician (73.8%, kappa 0.58).

Conclusions

Everyday consistency between raters from SU and RW in using mRS is modest as in previous validation studies. However, it may be considered sufficient for the purpose of observational studies or stroke registries. It emphasizes the need for easily accessible training in conventional mRS or implementation of specialized tools with predefined questions.

Blood Pressure Changes During Mechanical Thrombectomy for Acute Ischemic Stroke Are Associated With Serious Early Treatment Complications: Symptomatic Intracerebral Hemorrhage and Malignant Brain Edema

Background

Symptomatic intracranial hemorrhage (sICH) and malignant brain edema (MBE) are well-known deleterious endovascular treatment (EVT) complications that some studies found to be associated with postprocedural blood pressure (BP) variability. We aimed to evaluate their association with periprocedural BP changes, including its intraprocedural decrease.

Methods

We retrospectively analyzed the data of 132 consecutive patients that underwent EVT between 1 December 2018 and 31 December 2019, for anterior circulation ischemic stroke. Analyzed predictors of sICH and MBE included non-invasively obtained BP before and 5-min after treatment, intraprocedural relative decreases of BP from baseline, and its post-treatment increases. SICH was defined in accordance with the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria and MBE as brain edema with midline shift on the follow-up imaging. We used binary logistic regression analysis to investigate the association of BP parameters and the incidence of sICH and MBE.

Results

Among the included patients, 11 (8.3%) developed sICH and 31 (23.5%) MBE. The intraprocedural decrease of mean arterial blood pressure (MAP) was independently associated with MBE occurrence (aOR per 10 mmHg drop from baseline 1.27; 95% CI 1.01–1.60; P = 0.040). Over 40% MAP drop was associated with a higher risk of sICH in the entire cohort (aOR 4.24; 95% CI 1.33–13.51; P = 0.015), but not in the subgroup with successful reperfusion (aOR 2.81; 95% CI 0.64–12.23; P = 0.169). Post-treatment systolic blood pressure (SBP) and MAP elevation above their minimal values during MT are significantly associated with the development of sICH (aOR per 10 mmHg SBP increase 1.78; 95% CI 1.15–2.76; P = 0.010 and aOR per 10 mmHg MAP increase 1.78; 95% CI 1.04–3.03; P = 0.035).

Conclusions

In the anterior circulation ischemic stroke patients relative MAP decrease during EVT is associated with a higher risk of MBE occurrence, and over 40% MAP drop with a higher incidence of both MBE and sICH. Post-treatment elevation of SBP and MAP increased the risk of sICH.

A Scoping Review of Non-Pharmacological, Non-Surgical Secondary Prevention Strategies in Ischaemic Stroke and TIA in National Stroke Guidelines and Clinical Audit Documents

The Stroke Action Plan for Europe (2018–2030) calls for national-level secondary prevention plans that address lifestyle, in addition to prevention medications and surgical interventions. This scoping review examines national stroke care guideline and audit documents across WHO regions to identify non-pharmacological, non-surgical stroke secondary prevention recommendations and associated performance indicators. Using a snowballing methodology, 27 guideline documents met the inclusion criteria. Sixteen (59%) detailed, non-pharmacological, non-surgical stroke secondary prevention-addressing known, modifiable population attributable risk factors, of physical inactivity (N = 11), smoking (N = 11), unsafe alcohol consumption (N = 10), diet (N = 8), weight (N = 5), stress (N = 4) and depression (N = 2). Strategies recommended to address these risk factors were: assessment of stroke risk/risk factors (N = 4); provision of advice and information on reducing lifestyle related risk (N = 16); education and counselling for lifestyle behaviour change (N = 8) and onward referral for specialist management of risk (N = 4). Of the nine stroke audits/registries identified, only three (33%) included non-pharmacological, non-surgical quality indicators of documented provision of advice or information on the following: general lifestyle (N = 2); smoking cessation for current smokers (N = 2); reduction in alcohol consumption, where relevant (N = 1), exercise participation (N = 1) and diet (N = 1). Preventive quality indicators addressing the management of weight, stress or depression were absent. This review highlights current gaps in optimal stroke secondary prevention recommendations and their implementation.

Predictors of favorable outcome after endovascular thrombectomy for acute ischemic stroke due to large vessel occlusion in young patients

BACKGROUND

Mechanical thrombectomy (MT) became a standard of care for patients with acute ischemic stroke (AIS) with its efficacy demonstrated by meta-analysis and randomized studies. Although ischemic stroke is associated more with older patients, it may also have devastating neurological effects on young patients.

PURPOSE

To present our experience with stroke patients aged <50 years treated with endovascular means and to evaluate clinical and procedural factors associated with outcome and mortality.

MATERIAL AND METHODS

This study was conducted on 34 young stroke patients treated with MT. Clinical features including baseline results, radiological imaging, procedural details, and outcome results were documented and evaluated. Recanalization was assessed according to the TICI score. The clinical condition was evaluated after three months using mRS. Mortality rate was calculated.

RESULTS

The rate of successful recanalization (TICI ≥2c) was 79% (27/34). Symptomatic intracranial hemorrhage (sICH) was observed in 5 (15%) patients. After 90 days, the mortality rate was 12%. Favorable clinical outcome (mRs 0-2) was regained in 65% of the patients whereas satisfactory clinical outcome was seen in 85%. Poor clinical outcome (mRs >2) was observed in 9 (23.7%) patients.

CONCLUSION

In conclusion, the results of this study demonstrate that MT for AIS in young patients is feasible and provides an excellent rate of arterial recanalization and high rate of favorable outcomes. Statistical analysis showed that shorter time from onset to arrival and reperfusion, successful recanalization and absence of hemorrhagic transformation are the predictors of favorable clinical outcome and overall survival rate.

Fibromuscular Dysplasia/Carotid Web in Angio-CT Imaging: A Rare Cause of Ischemic Stroke

Background and Objectives: Carotid web (CaW) is an intimal variant of fibromuscular dysplasia and may constitute as one of rare causes of acute ischemic stroke (AIS). The objective of this study was to determine the prevalence of CaW in patients with AIS or transient ischemic attack (TIA) based on head/neck CT angiography (CTA) in a Polish cohort study. Materials and Methods: A retrospective study was performed by analyzing 1480 electronic clinical and imaging data regarding patients with AIS or TIA, hospitalized in the years 2018–2020 in the authors’ institution. The final sample consisted of 181 patients who underwent head/neck CTA; aged 67.81 ± 13.51 years (52% were women). All head/neck CTA studies were independently evaluated by two radiologists. The patient’s clinical condition was assessed with the National Institutes of Health Stroke Scale (NIHSS, 5.76 ± 4.05 and 2.88 ± 3.38 at admission and at discharge, respectively). Results: 27 patients were identified with CaW. The prevalence of CaW in the final sample (181 pts with good quality CTA) was 14.9%. In the CaW group, 89% patients had AIS, including 26% diagnosed with recurrent and 11% with cryptogenic strokes. There were no significant differences between the presence of CaW and gender, age, NIHSS score, recurrent or cryptogenic stroke. Conclusions: Our study demonstrated that CaW may be an underrecognized entity leading to cerebrovascular events. The diagnosis of CaW depends on a high level of awareness and a comprehensive analysis of the neuroimaging studies. Our findings support the hypothesis that it is worthwhile to perform CTA to determine the etiology of ischemic stroke, particularly if predicting factors were not identified.

Mechanical thrombectomy for acute ischemic stroke in the posterior circulation: assessment of efficacy and outcome and identification of prognostic factors

BACKGROUND

Mechanical thrombectomy (MT) is well-established in the treatment of acute ischemic anterior circulation stroke. However, there is no evidence from randomized trials or meta-analyses that MT is safe and effective in the treatment of patients with acute ischemic posterior circulation stroke (PCS).

PURPOSE

To evaluate the clinical and procedural factors associated with recanalization and outcome of patients with PCS treated with MT.

MATERIAL AND METHODS

Forty-three patients with PCS (median age 73 years) who underwent treatment with MT were included. Data including demographics, baseline stroke severity, radiological imaging, procedure and post-procedure complications were documented. Clinical outcome was evaluated using the modified Rankin Scale (mRS). The patients were classified into two groups based on clinical outcome (favorable vs. unfavorable mRS after 90 days).

RESULTS

Median baseline National Institute of Health Stroke Scale (NIHSS) was 17. Twenty patients were eligible for intravenous thrombolysis and received recombinant tissue plasminogen activator before MT. Successful recanalization was observed in 88.4% of patients. After 90 days, favorable outcome (defined as mRS 0-2) was achieved in 26 patients; six patients had an unfavorable outcome (mRs >2). Final mortality rate was 25.5%. Baseline NIHSS, onset to reperfusion time, procedure duration, and successful recanalization had a statistically significant association with outcome. Failed recanalization and occurrence of intracranial hemorrhage were found to be associated with a higher mortality rate.

CONCLUSION

MT is feasible and effective method in treatment of PCS. Baseline NIHSS and onset to reperfusion time were found to be independent predictive factors of clinical outcome.

Stroke Care During the First and the Second Waves of the COVID-19 Pandemic in a Community Hospital

Objective: The coronavirus disease 2019 (COVID-19) infection may alter a stroke course; thus, we compared stroke course during subsequent pandemic waves in a stroke unit (SU) from a hospital located in a rural area. Methods: A retrospective study included all patients consecutively admitted to the SU between March 15 and May 31, 2020 ("first wave"), and between September 15 and November 30, 2020 ("second wave"). We compared demographic and clinical data, treatments, and outcomes of patients between the first and the second waves of the pandemic and between subjects with and without COVID-19. Results: During the "first wave," 1.4% of 71 patients were hospitalized due to stroke/TIA, and 41.8% of 91 during the "second wave" were infected with SARS-CoV-2 (p < 0.001). During the "second wave," more SU staff members were infected with COVID-19 than during the "first wave" (45.6 vs. 8.7%, p < 0.001). Nevertheless, more patients underwent intravenous thrombolysis (26.4 vs. 9.9%, p < 0.008) and endovascular thrombectomy (5.3 vs. 0.0%, p < 0.001) during the second than the first wave. Large vessel occlusion (LVO) (OR 8.74; 95% CI 1.60-47.82; p = 0.012) and higher 30-day mortality (OR 6.01; 95% CI 1.04-34.78; p = 0.045) were associated with patients infected with COVID-19. No differences regarding proportions between ischemic and hemorrhagic strokes and TIAs between both waves or subgroups with and without COVID-19 existed. Conclusion: Despite the greater COVID-19 infection rate among both SU patients and staff during the "second wave" of the pandemic, a higher percentage of reperfusion procedures has been performed then. COVID-19 infection was associated with a higher rate of the LVO and 30-day mortality.

Cerebral Thrombolysis in Rural Residents Aged ≥ 80

Purpose

The proportion of older people in Poland is higher in rural areas than in urban areas. Thus, we aimed to evaluate treatment rate and factors associated with outcome and safety of intravenous thrombolysis (IVT) in rural residents aged ≥80 years admitted to primary stroke centers.

Patients and Methods

This study was a retrospective, observational cohort study of 873 patients treated with recombinant tissue plasminogen activator (rt-PA) in primary stroke centers between February 1, 2009 and December 31, 2017. Among them were 527 rural residents and 231 (26.5%) were ≥80 years of age. The analyses between rural and urban patients aged ≥80 and between rural patients aged <80 and aged ≥80 were performed.

Results

The proportion of patients aged ≥80 treated with rt-PA was comparable in rural and urban residents (27.9% vs 24.3% p = 0.24). Rural patients aged ≥80 were also characterized by lower incidence of cardiovascular risk factors and better patients’ conditions on admission to hospital. Symptomatic intracerebral hemorrhage rate among ≥80-year-old stroke patients was lower in those living in rural areas than in those living in urban areas (5.4% vs 14.3%, p = 0.02); there were no differences regarding mortality and 3-month functional outcome between both populations. The older group of rural patients was characterized by a higher 3-month mortality (28.5% vs 12.6%, p < 0.001) and lower functional independence rate (34.0% vs 50.5%, p < 0.001) than rural younger patients. Antiplatelet (OR 2.43, 95% CI 1.04–5.66, p = 0.04) and anticoagulant therapy before stroke (OR 3.64, 95% CI 1.21–10.99, p = 0.022), early ischemic changes in baseline computerized tomograprpahy (OR 2.65, 95% CI 1.03–6.82, p = 0.043) were associated with unfavorable outcome; and higher National Institute of Health Stroke Scale score on admission (OR 1.01, 95% CI 1.01–1.20, p = 0.039), higher baseline count of white blood cells (OR 1.33, 95% CI 1.10–0.62, p = 0.003) were associated with mortality in rural patients over 80.

Conclusion

We suggest that rural patients aged ≥80 may be safely treated with IVT in routine practice. However, lower efficacy and a higher mortality must be considered in former use of Vitamin K antagonist and antiplatelet or high white blood cells count.

Neuropsychological rehabilitation of acquired, non-progressive cognitive-behavioral disorders in evidence-based clinical recommendations

Introduction: Neuropsychological rehabilitation is an important area of neurological rehabilitation. Its techniques are studied in terms of effectiveness and subjected to collective analyses in order to identify the best interventions. Objective: The purpose of the article is to present current clinical recommendations for neuropsychological rehabilitation among adult patients with acquired, non-progressive brain damage usually caused by a stroke or head injury. Data sources: The recommendations are based on the latest scientific papers containing systematic reviews and meta-analysis of studies on the rehabilitation of patients with cognitive dysfunctions and/or behavioral abnormalities. Conclusions: To date, the highest recommendation and the status of practice standards in neuropsychological rehabilitation have been achieved by therapeutic techniques of 5 post-stroke disorders (attention deficits, mild memory deficits, left-sided visual neglect, aphasia, global decline in cognitive-behavioral functioning) and 5 post-traumatic disorders (attention deficits, mild memory deficits, mild and moderate executive dysfunctions, abnormalities in social functioning and interpersonal communication, global decline in cognitive-behavioral functioning). These techniques may be used independently or introduced in combination with interventions of a lower recommendation level, classified as practice guidelines or practice options. The use of lower grade recommendations should also be considered in situations where there are no standard techniques for specific forms of disorders. In the case of deficits for which no recommendations have yet been made, further research is necessary. This applies to agnosia, profound memory disorders and amnesia, as well as profound executive dysfunctions.

Effect of IL-6 and hsCRP Serum Levels on Functional Prognosis in Stroke Patients Undergoing IV-Thrombolysis: Retrospective Analysis

Purpose

We evaluated the relationship between pretreatment IL-6 and hsCRP levels, symptom severity and functional outcome of patients with acute ischemic stroke (AIS) treated with IV-thrombolysis.

Patients and Methods

IL-6 and hsCRP samples were obtained from 83 consecutively treated Caucasian patients with AIS prior to initiation of IV-thrombolysis. Severity of stroke symptoms was assessed using the National Institutes of Health Stroke Scale (NIHSS), whereas functional outcome was assessed with modified Rankin Scale (mRS). The commercially available sets of enzymatic immune tests were used to estimate the concentrations of inflammatory markers in serum.

Results

Medians of IL-6 serum concentrations prior to IV-thrombolysis were lower in patients with favorable (mRS 0-2 pts) functional outcome than in those with unfavorable (mRS 3-6 pts) functional outcome, both at hospital dismission (5.92: 2.30-7.71 vs 9.46: 3.79-17.29 pg/mL; p<0.01) and on the ninetieth day from stroke onset (5.87: 2.30-10.58 vs 10.9: 5.94-17.28 pg/mL; p<0.01). There were no existing differences regarding hsCRP levels between groups (2.49: 0.11-9.82 vs 4.44: 0.32-9.87 mg/dL; p=0.30 and 2.57: 0.11-2.57 vs 2.83: 0.32-9.32 mg/dL; p=0.75, respectively). Patients with lacunar strokes were characterized by lower median of IL-6 (5.96: 2.87-13.0% vs 7.29: 2.30-17.28; p=<0.02) and hsCRP (2.25: 0.11-9.82 vs 4.84: 0.35-9.87; p=0.01) than those with nonlacunar infarctions. Multivariate analysis showed an impact of IL-6 on mRS measured on hospital dismission and after three months, regardless of their initial NIHSS, presence of hemorrhagic transformation and type 2 diabetes. No impact of hsCRP, lacunar etiology and patients' age on functional outcome existed.

Conclusion

Regardless of the stroke etiology, pretreatment of IL-6, but not of hsCRP levels, may help to predict functional outcome after IV-thrombolysis independently of symptom severity and stroke complications.

The cost-effectiveness of food consistency modification with xanthan gum-based Nutilis Clear® in patients with post-stroke dysphagia in Poland

Background

Dysphagia is a well-known stroke complication characterised by difficulty in swallowing. It may affect the majority of stroke patients and increases mortality and morbidity, due to aspiration pneumonia and malnutrition. Food thickening may help patients to feed themselves, and its effectiveness was demonstrated. However, the cost-effectiveness studies are lacking. We evaluate the cost-utility of xanthan gum-based consistency modification therapy (Nutilis Clear®) in adult post-stroke patients from the public payer perspective in Poland.

Methods

Routine clinical practice was used as a comparator, as no alternative specific treatment for dysphagia is available. To verify the robustness of the results against the modelling approach, we built two models: a static (a fixed simple-equations model, 8-week time horizon of dysphagia) and a dynamic one (Markov model, with a possible dysphagia resolution over a 1-year horizon). In both models, the treatment costs, health state utilities, and clinical events (i.e. aspiration, aspiration pneumonia, death) were included. Parameters were estimated jointly for both models, except for the duration of dysphagia and the risk of aspiration pneumonia (specific to the time horizon). We only assumed Nutilis Clear® to prevent aspirations, without affecting dysphagia duration.

Results

The average cost of one quality-adjusted life year (i.e. the incremental cost-utility ratios, ICURs) amounted to 21,387 PLN (€1 ≈ 4.5 PLN), and 20,977 PLN in static and dynamic model, respectively; far below the cost-effectiveness threshold in Poland (147,024 PLN). The one-way, scenario, and probabilistic sensitivity analysis confirmed these findings.

Conclusions

Nutilis Clear® is highly cost-effective in Poland from the public payer perspective. Our approach can be used in other countries to study the cost-effectiveness of food thickening in stroke patients.