[show abstract][hide abstract] ABSTRACT: Despite efforts to arrive at a diagnosis, the cause of stroke remains undetermined in 25% to 40% of patients. Factors contributing to undetermined causes of stroke include inadequate information about the underlying vascular pathology, ill-timed diagnostic workup, and incomplete evaluation. Fortunately, mounting evidence suggest that advanced diagnostic techniques may have great use in reducing the proportions of strokes of undetermined cause. For instance, long-term monitoring to document paroxysmal atrial fibrillation, high-resolution MRI technique to visualize wall pathology (ie, plaque, dissection, or vasculitis), coronary computed tomographic angiography to better establish potential sources of aortocardiac embolism, and laboratory tests for cancer-related coagulopathy can all assist with prompt identification of underlying stroke mechanisms and guide early specific treatments to improve stroke outcomes. Still, conducting many of the aforementioned advanced diagnostic techniques can be time-consuming and expensive, and so careful selection and judicious use of the most appropriate diagnostic modalities, guided by patients' characteristics at the time of presentation, are crucial. This review article provides an overview of the promising role of various advanced diagnostic techniques in the approach to deciphering the so-called cryptogenic strokes. It details sophisticated tools that have the potential to better inform clinicians caring for patients with stroke about the causative mechanisms at play (and, therefore, distinctive treatments that may be required) and presents pragmatic strategies for using these procedures in routine practice although the effectiveness of such strategies need to be tested in future longitudinal studies.
[show abstract][hide abstract] ABSTRACT: Dual-antiplatelet regimens for prevention of recurrent stroke promote antithrombotic effects but may increase the risk for hemorrhage.
To qualitatively and quantitatively examine the risk for recurrent stroke and intracranial hemorrhage (ICH) linked to long-term dual- and single-antiplatelet therapy among patients with ischemic stroke and transient ischemic attack.
PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials through March 2013 without language restrictions.
The search identified 7 randomized, controlled trials that involved a total of 39 574 participants and reported recurrent stroke and ICH as outcome measures.
All data from eligible studies were independently abstracted by 2 investigators according to a standard protocol.
Recurrent stroke risk did not differ between patients receiving dual-antiplatelet therapy and those receiving aspirin monotherapy (relative risk [RR], 0.89 [95% CI, 0.78 to 1.01]) or clopidogrel monotherapy (RR, 1.01 [CI, 0.93 to 1.08]). Risk for ICH did not differ between patients receiving dual-antiplatelet therapy and those receiving aspirin monotherapy (RR, 0.99 [CI, 0.70 to 1.42]) but was greater among patients receiving dual-antiplatelet therapy than among those receiving clopidogrel monotherapy (RR, 1.46 [CI, 1.17 to 1.82]).
Agents used in dual- and single-antiplatelet therapies varied across trials, and the relatively modest number of trials limited subgroup analysis.
Compared with monotherapy, dual-antiplatelet therapy lasting more than 1 year after an index ischemic stroke or transient ischemic attack is not associated with a greater reduction in overall recurrent stroke risk. However, long-term dual-antiplatelet therapy is linked to higher risk for ICH than clopidogrel monotherapy in this patient population.
Chang Gung Memorial Hospital.
Annals of internal medicine 10/2013; 159(7):463-470. · 13.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: Although the ambulatory setting is recognized as the best arena for optimizing antihypertensive drug treatment after a stroke, little is known about recent office-based antihypertensive drug treatment patterns in the United States. We assessed national trends in antihypertensive treatment for stroke patients in office-based medical practice.
Data from the 2000-2009 National Ambulatory Medical Care Surveys were analyzed comprising outpatient visits to physicians in office-based practice by patients aged 40 years or older with a diagnosis of stroke (weighted estimate = 46,317,269). The main outcome measure was visits with a prescription of antihypertensive medication(s).
The proportion of total visits that included a prescription of antihypertensive medication was 35.6% in 2000-2002, 29.5% in 2003-2005, and 49.3% in 2006-2009 (P = .002); 50.9% were primary care physician (PCP) visits versus 26.2% neurologist visits (P < .0001). Age-adjusted logistic regression analyses confirmed a higher prescription rate in 2006-2009 versus 2000-2002 (1.81; 95% confidence interval [CI], 1.10-2.96) and PCP versus neurologists (2.82; 95% CI, 1.86-4.27). Use of 2 or more agent classes was 31.6% in 2000-2002, 44.2% in 2003-2005, and 56.7% in 2006-2009 (P = .014). Age-adjusted logistic regression analyses confirmed a higher prescription rate of 2 or more agent classes in 2006-2009 versus 2000-2002 (2.96; 95% CI, 1.40-6.24). There were no significant differences in agent class type or number between neurologists versus PCPs.
Over the last decade, there was a significant rise in the use of antihypertensive drugs and combination of agent classes for patients aged 40 years or older seen in an ambulatory setting with a diagnosis of stroke. PCPs were more likely than neurologists to prescribe these agents.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 07/2013;
[show abstract][hide abstract] ABSTRACT: To investigate the relationship between chronic kidney disease (CKD) and MRI-defined cerebral microbleeds (CMB), a harbinger of future intracerebral hemorrhage (ICH), among patients with a recent history of primary ICH.
Using data from a predominantly black cohort of patients with a recent ICH-enrolled in an observational study between September 2007 and June 2011, we evaluated the association between CKD (defined as estimated low glomerular filtration rate<60 mL/min per 1.73 m(2)) and CMB on gradient-echo MRI. Multivariable models were generated to determine the contribution of CKD to the presence, number, and location of CMB.
Of 197 subjects with imaging data, mean age was 59 years, 48% were women, 73% were black, 114 (58%) had ≥1 CMBs, and 52 (26%) had CKD. Overall, CKD was associated with presence of CMB (adjusted odds ratio, 2.70; 95% confidence interval [CI], 1.10-6.59) and number of CMB (adjusted relative risk, 2.04; 95% CI, 1.27-3.27). CKD was associated with CMB presence (adjusted odds ratio, 3.44; 95% CI, 1.64-7.24) and number (adjusted relative risk, 2.46; 95% CI, 1.11-5.42) in black patients, but not CMB presence (adjusted odds ratio, 3.00; 95% CI, 0.61-14.86) or number (adjusted relative risk, 1.03; 95% CI: 0.22-4.89) in non-Hispanic white patients (interactions by race were statistically not significant).
CKD is associated with a greater presence and number of CMB in ICH patients, particularly in patients of black race. Future studies should assess whether low estimated glomerular filtration rate may be a CMB risk marker or potential therapeutic target for mitigating the development of CMB.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Studies suggest that women are less likely than men to receive intravenous (IV) tissue plasminogen activator (tPA) for acute ischemic stroke (AIS). Relatively little is known about whether this sex disparity in AIS management extends beyond IV tPA use, reflects national practice patterns, or is changing. METHODS: Data from the Nationwide Inpatient Sample from 1997 to 2006 were used to identify adults (≥18 years of age) who were discharged with a primary diagnosis of AIS (n = 4,453,207) in the United States. Of 605,960 individuals admitted to 1056 hospitals that performed reperfusion/revascularization procedures, sex-specific rates of cerebrovascular reperfusion (e.g., IV tPA, intra-arterial therapy, angioplasty, stent, or carotid endarterectomy [CEA]), and cardiac reperfusion (e.g., catheterization, angioplasty, stent, or bypass graft) were determined before and after adjustment for sociodemographic, clinical, and hospital factors. RESULTS: Men were more likely than women to receive IV tPA (prevalence ratio (PR) 1.37, 95% confidence interval [CI] 1.32-1.42), catheter angiography (PR 1.36, 95% CI 1.33-1.38), intracranial or extracranial angioplasty/stent (PR 1.73, 95% CI 1.49-2.01), CEA (PR 1.79, 95% CI 1.72-1.86), or any cardiac reperfusion therapy (PR 1.62, 95% CI 1.53-1.71). Multivariable adjustment slightly attenuated the sex disparity. Use of all procedures except CEA rose from 1997 to 2006 in both sexes, but IV tPA use increased at a higher rate for women (compared to men); by 2006, there was no sex difference. CONCLUSIONS: Over the last decade, women hospitalized for AIS in the United States were less likely than men to receive cerebrovascular and cardiac reperfusion therapies. However, the IV tPA treatment sex disparity may have been eliminated.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 05/2013;
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Low estimated glomerular filtration rate (eGFR) has been linked to higher risk of primary stroke, but little is known about the relation of low eGFR to recurrent vascular risk after stroke. B Vitamin therapy has been used to lower homocysteine levels, but its interaction with kidney function on future major vascular events has not been assessed. The objective of this study was to conduct a secondary analysis based on the Vitamin Intervention for Stroke Prevention (VISP) trial to clarify these issues. STUDY DESIGN: In the VISP trial, patients with a prior ischemic stroke were randomly assigned to receive the high- or low-dose B vitamin therapy. The trial did not find a difference between randomly assigned groups. The present study is a secondary analysis of the VISP trial. SETTING & PARTICIPANTS: We analyzed the database of a multicenter trial comprising 3,673 patients with recent ischemic stroke who were followed up for 2 years. PREDICTOR: We subdivided the cohort based on eGFR into 6 groups (≥105, 90-104, 75-89, 60-74, 45-59, and <45 mL/min/1.73 m(2)) for the analyses and used eGFR of 60-74 mL/min/1.73 m(2) as the reference category. Low eGFR was defined as <45 mL/min/1.73 m(2). OUTCOMES: The primary end point for this analysis was major vascular events, defined as the composite of nonfatal ischemic stroke, nonfatal myocardial infarction, and vascular death (whichever event came first). The secondary end point was recurrent ischemic stroke. Also, the effects of high-dose B vitamin treatment on future major vascular events according to baseline eGFR categories were analyzed and reported separately. RESULTS: Mean baseline eGFR was 73.9 ± 21.8 (SD) mL/min/1.73 m(2). 471 major vascular events during an average of 20 months of follow-up, including 300 recurrent strokes, were recorded. Baseline low eGFR was associated with increased risk of major vascular events (HR, 1.83; 95% CI, 1.32-2.52; P < 0.001) and recurrent stroke (HR, 1.53; 95% CI, 1.01-2.32; P = 0.04) after adjustment for traditional vascular risk factors and homocysteine level. At baseline eGFR <45 mL/min/1.73 m(2), high-dose B vitamin therapy compared to low dose showed a trend of higher risk of future major vascular events (HR, 1.49; 95% CI, 0.95-2.34; P = 0.08). The overall P value for interaction between B vitamin dose and eGFR was not significant (P = 0.6). LIMITATIONS: No data for albuminuria. CONCLUSIONS: Low eGFR is associated with higher risk of future major vascular events and recurrent stroke after a recent ischemic stroke.
American Journal of Kidney Diseases 04/2013; · 5.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: The comparative relationships of widely recognized biomarkers of renal injury with short-term and long-term outcomes among critically ill acute stroke patients are unknown. We evaluated the impact of baseline albuminuria [urine albumin-creatinine ratio (UACR)≥30 mg/g] or low estimated glomerular filtration rate (eGFR<60 ml/min per 1.73 m(2)) on stroke patients admitted to the intensive care unit (ICU).
We reviewed data on consecutive stroke patients admitted to a hospital ICU in Taiwan from September 2007 to August 2010 and followed-up for 1 year. Baseline UACR was categorized into <30 mg/g (normal), 30-299 mg/g (microalbuminuria), and ≥300 mg/g (macroalbuminuria), while eGFR was divided into ≥60, 45-59, and <45 ml/min per 1.73 m(2). The outcome measure was death or disability at 3-month and 1-year after stroke onset, assessed by dichotomizing the modified Rankin Scale at 3-6 versus 0-2.
Of 184 consecutive patients, 153 (83%) met study entry criteria. Mean age was 67.9 years and median admission NIHSS score was 16. Among the renal biomarkers, only macroalbuminuria was associated with poorer 3-month outcome (OR 8.44, 95% CI 1.38 to 51.74, P = 0.021) and 1-year outcome (OR 18.06, 95% CI 2.59 to 125.94, P = 0.003) after adjustment of relevant covariates. When ischemic and hemorrhagic stroke were analyzed separately, macroalbuminuria was associated with poorer 1-year outcome among ischemic (OR 17.10, 95% CI 1.04 to 280.07, P = 0.047) and hemorrhagic stroke patients (OR 1951.57, 95% CI 1.07 to 3561662.85, P = 0.048), respectively, after adjustment of relevant covariates and hematoma volume.
Presence of macroalbuminuria indicates poor 3-month and 1-year outcomes among critically ill acute stroke patients.
PLoS ONE 01/2013; 8(9):e72971. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: -The risk-benefit profile of warfarin versus aspirin for patients with heart failure in normal sinus rhythm has not been definitively established. Our objective was to evaluate the overall comparative effects of warfarin and aspirin in patients with heart failure and normal sinus rhythm. METHODS AND RESULTS: -Pubmed, EMBASE, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from 1966 to June 2012 were searched to identify relevant studies. We included randomized controlled trials that included comparison of warfarin vs. aspirin, and composite endpoint of death or stroke separately for active treatment and control groups. Summary incidence rates, relative risks (RRs), and 95% confidence intervals (CIs) were calculated using random-effects models. The search identified 4 randomized controlled trials of warfarin vs. aspirin therapy, enrolling 3663 patients. There was no significant difference between the two treatments for the primary endpoint (warfarin vs. aspirin: RR 0.94, 95% CI: 0.84 to 1.06, p=0.31). Warfarin (vs. aspirin) was associated with lower risk of any stroke (RR 0.56, 95% CI: 0.38 to 0.82, p=0.003) and ischemic stroke (RR 0.45, 95% CI: 0.24 to 0.86, p=0.02) but had a neutral effect on death (RR 1.01, 95% CI: 0.89-1.14, p=0.89) and a higher risk of major bleeding (RR 1.95, 95% CI 1.37 to 2.76, p=0.0002). CONCLUSIONS: -Compared to aspirin, warfarin does not provide benefit in the prevention of stroke and death among patients with heart failure in sinus rhythm, but raises the risk of major bleeding; and therefore its use in these patients is not justified.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Cancer, by conferring a hypercoagulable state, may lead to an ischemic stroke. Relatively little is known about the prevalence and evolution of cancer among stroke patients over the last decade. METHODS: We used the Nationwide Inpatient Sample to identify discharges with any InternationalClassification of Diseases, Ninth Revision, diagnosis code for cancer and ischemic stroke from 1997 to 2006. We then calculated age-adjusted yearly acute ischemic stroke hospitalization rates among adult populations with and without cancer. RESULTS: Prevalence of cancer among hospitalized stroke patients increased from 1997 to 2006 (N = 31,075 [9.1% of all ischemic stroke hospitalizations] to 34,138 [10.6%], P < .0001). The most common types of cancer among hospitalized stroke patients in 1997 and 2006 were prostate (21% versus 19%), breast (19% versus 19%), gastrointestinal (16% versus 13%), and colorectal (13% versus 13%). Over the decade there was a significant decrease in the prevalence of stroke hospitalizations (slope -3.02, 95% confidence interval -3.69 to -2.34), but not among cancer patients (slope 1.35, 95% confidence interval -0.88 to 3.58). CONCLUSION: About 1 in 10 hospitalized ischemic stroke patients in the United States has comorbid cancer, and there has been a slight rise in this rate over the last decade. This is likely due to enhanced survival from better cancer treatments, but further study is warranted.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 12/2012;
[show abstract][hide abstract] ABSTRACT: OBJECTIVES: Age and stroke severity are major determinants of stroke outcomes, but systematically incorporating these prognosticators in the routine practice of acute ischemic stroke can be challenging. We evaluated the effect of an index combining age and stroke severity on response to IV tissue plasminogen activator (tPA) among patients in the National Institute of Neurological Disorders and Stroke (NINDS) tPA stroke trials. METHODS: We created the Stroke Prognostication using Age and NIH Stroke Scale (SPAN) index by combining age in years plus NIH Stroke Scale (NIHSS) ≥100. We applied the SPAN-100 index to patients in the NINDS tPA stroke trials (parts I and II) to evaluate its ability to predict clinical response and risk of intracerebral hemorrhage (ICH) after thrombolysis. The main outcome measures included ICH (any type) and a composite favorable outcome (defined as a modified Rankin Scale score of 0 or 1, NIHSS ≤1, Barthel index ≥95, and Glasgow Outcome Scale score of 1) at 3 months. Bivariate and multivariable logistic regression analyses were used to determine the association between SPAN-100 and outcomes of interest. RESULTS: Among 624 patients in the NINDS trials, 62 (9.9%) participants were SPAN-100 positive. Among those receiving tPA, ICH rates were higher for SPAN-100-positive patients (42% vs 12% in SPAN-100-negative patients; p < 0.001); similarly, ICH rates were higher in SPAN-100-positive patients (19% vs 5%; p = 0.005) among those not receiving tPA. SPAN-100 was associated with worse outcomes. The benefit of tPA, defined as favorable composite outcome at 3 months, was present in SPAN-100-negative patients (55.4% vs 40.2%; p < 0.001), but not in SPAN-100- positive patients (5.6% tPA vs 3.9%; p = 0.76). Similar trends were found for secondary outcomes (e.g., symptomatic ICH, catastrophic outcome, discharge home). CONCLUSION: The SPAN-100 index could be a simple method for estimating the clinical response and risk of hemorrhagic complications after tPA for acute ischemic stroke. These results need further confirmation in larger contemporary datasets.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Concerns about ready access to neurosurgery after acute ischemic stroke (AIS) may delay or prevent intravenous thrombolysis, thereby leading to poor outcomes. A randomized trial exploring the need for back-up neurosurgery in AIS is unlikely. However, insight may be gained from routine clinical practice. We analyzed the odds and temporal trends of cranial neurosurgery procedure use in patients with AIS using a large U.S. administrative database. METHODS: Data from AIS patients in the Nationwide Inpatient Sample (October 1998 to 2006) who underwent a cranial neurosurgical procedure were analyzed. Multivariate logistic regression with covariate adjustment was used for statistical analysis. Results were stratified by thrombolysis status. Intracerebral hemorrhage (ICH) was used as a key covariate. RESULTS: Intravenous thrombolysis use increased significantly over time (0.8% to 2.5%; P < .001). Cranial neurosurgical procedures were observed infrequently but increased significantly over time (0.12% to 0.19%; P = .0013), and thrombolysis doubled the odds of a procedure (odds ratio 2.18; 95% confidence interval 1.48-3.21; P < .001). However, thrombolysis only significantly increased the odds of a neurosurgical procedure in the absence of ICH (P < .001). CONCLUSIONS: Thrombolysis should probably not be withheld from eligible AIS patients, even if a concern exists about the lack of readily available neurosurgery, because neurosurgical procedure use is low in routine clinical practice, even after intravenous thrombolysis. Future studies and prospective data might help define the need for standby neurosurgery after AIS and provide further focus on the specific linkage to ICH as a possible mediator variable.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 11/2012;
[show abstract][hide abstract] ABSTRACT: Background-Recent clinical trial data suggest that protease-activated receptor-1 (PAR-1) antagonists may increase the risk of intracranial hemorrhage. Our objective was to investigate the qualitative and quantitative risks of intracranial hemorrhage in patients receiving PAR-1 antagonist therapy. METHODS: Pubmed, EMBASE, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from 1966 to May 2012, included a comparison of PAR-1 antagonist with placebo and in which the total number of patients and intracranial hemorrhage events were reported separately for active treatment and control groups. Summary incidence rates, relative risks, and 95% confidence intervals (CIs) were calculated using random-effects models. Between-study heterogeneity was assessed using the I(2) statistic. RESULTS: In 9 PAR-1 antagonist trials with 42 000 patients with a history of thrombotic vascular disease or acute coronary syndrome, PAR-1 antagonist treatment was associated with increased risk of intracranial hemorrhage (0.59% vs 0.30%;, 1.98; 95% CI, 1.46-2.68; P<0.00001; number needed to harm, 345). There was no heterogeneity across trials (P=0.84; I(2)=0%), PAR-1 antagonist agent (P=0.52), treatment duration (P=0.38), or trial-qualifying event (P=0.59). Risk of death from any cause or a cardiovascular cause did not differ between active treatment and control groups. CONCLUSIONS: PAR-1 antagonist therapy was associated with an increased risk for intracranial hemorrhage.
[show abstract][hide abstract] ABSTRACT: Coronary heart disease (CHD) is a major cause of mortality among stroke patients after the acute period. Simple risk stratification of stroke patients without known CHD may permit prompt implementation of CHD-specific management strategies for those who are at high risk for cardiac events. We assessed the utility of the Framingham Coronary Heart Disease Risk Score (FCRS) as a prognosticator in stroke patients without known CHD.
Post hoc analysis of a trial dataset of 3509 recent ischemic stroke patients who were aged 35 years or older, recruited from 56 centers, and followed-up for 2 years. Patients were categorized as having known CHD, high FCRS (≥20%), and low/intermediate FCRS (<20%). The predictive values between baseline FCRS and primary (myocardial infarction [MI]), secondary (MI or vascular death), and tertiary (recurrent stroke) outcomes were assessed in multivariate analyses.
Rates of first MI at 2 years were 6.34%, 4.65%, and 1.44% for the known CHD, high FCRS, and low/intermediate FCRS groups. Compared with stroke patients with low/intermediate FCRS, individuals with high FCRS had a higher risk of MI (adjusted hazard ratio, 3.70; 95% confidence interval, 2.14-6.38) and MI or vascular death (adjusted hazard ratio, 2.21; 95% confidence interval, 1.48-3.28). High FCRS did not predict recurrent stroke.
Among patients with a recent ischemic stroke without known CHD, high FCRS was associated with a higher risk of MI and vascular death, but not stroke. FCRS could be a simple way to identify recent stroke patients who may benefit from additional CHD-specific management.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: In observational studies, lower serum homocysteine levels are associated with a lower incidence of cardiovascular disease (CVD). However, individual randomized controlled trials (RCTs) have yielded mixed findings regarding the efficacy of therapeutic homocysteine in lowering cardiovascular risk. Our aim was to perform an updated meta-analysis of relevant RCTs to assess the efficacy of folic acid supplementation in the prevention of CVD, coronary heart disease (CHD), and stroke. METHODS: We performed systematic search to identify RCTs reported at least one of the CVD, CHD, or stroke as outcomes. Relative risk (RR) with 95% confidence interval was used as a measure of the association between folic acid supplementation and risk of CVD, CHD, stroke, and all-cause mortality. The analysis was further stratified by factors that could affect the treatment effects. RESULTS: The systematic search identified 26 RCTs enrolling 58,804 participants. Pooling the RRs showed that folic acid supplementation was not associated with any significant change in the risk of CVD (RR 0.98, 0.95 to 1.02; p=0.36), CHD (RR 1.03, 0.98 to 1.08; p=0.23), and all-cause mortality (RR 1.00, 0.96 to 1.04; p=0.92), but was linked to a decreasing trend in stroke risk (RR 0.93, 0.86 to 1.00; p=0.05). In stratified analyses, the only heterogeneity was found for stroke risk reduction among groups with (RR 1.07, 0.92 to 1.25) vs. without (RR 0.88, 0.81 to 0.96) mandatory grain fortification (P for heterogeneity=0.03). CONCLUSIONS: This meta-analysis suggests that there might be a potentially modest benefit of folic acid supplementation in stroke prevention.
European Journal of Internal Medicine 08/2012; · 2.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: The purpose of this study was to determine whether leukoaraiosis (LA) predicts hemorrhagic transformation and poor outcome in patients with acute ischemic stroke treated by mechanical thrombectomy.
We retrospectively analyzed patients with anterior circulation stroke treated with Merci devices and identified LA in the deep white matter (DWM) and periventricular white matter on the preintervention MR images. We dichotomized patients into those with moderate or severe LA in the DWM versus those without. Hemorrhage rates and outcomes were evaluated between 2 groups. We analyzed the association of moderate or severe LA with hemorrhagic transformation and poor outcome.
Twenty-six of 105 patients had moderate or severe LA in the DWM. Patients with moderate or severe LA in the DWM were older, had more severe neurological deficits and worse outcome, had higher rates of hemorrhagic transformation and parenchymal hematoma, but had equivalent rates of hemorrhagic infarct and subarachnoid hemorrhage when compared with those without. Patients with only periventricular LA did not have a higher rate of parenchymal hematoma. Moderate or severe LA in the DWM was an independent predictor of hemorrhagic transformation (OR, 3.4; P=0.019) and parenchymal hematoma (OR, 6.3; P=0.005). Patients with parenchymal hematoma were less often independent (modified Rankin Scale≤2, 3.8% versus 32.5%; P=0.003) and had greater in-hospital mortality (50% versus 10.4%; P<0.001).
Moderate or severe LA in the DWM increases the risk of parenchymal hematoma after Merci thrombectomy for patients with acute stroke. These findings require validation in a larger prospective study.
[show abstract][hide abstract] ABSTRACT: To investigate whether anterior choroidal artery (AChA) territory sparing or AChA infarction restricted to the medial temporal lobe (MT), implying good collateral status, predicts good outcome, defined as modified Rankin Scale 0-2, at discharge in acute internal carotid artery (ICA) occlusion.
The authors studied consecutive patients with acute ICA occlusion admitted to an academic medical centre between January 2002 and August 2010, who underwent MRI followed by conventional angiography. The pattern of AChA involvement on initial diffusion-weighted imaging was dichotomised as spared or MT only versus other partial or full. The association of AChA infarct patterns and good outcome at discharge was calculated by multivariate logistic regression with adjustment.
For the 60 patients meeting entry criteria, mean age was 68.3 years and median admission NIH Stroke Scale score was 19. AChA territory was spared or restricted to the MT in 27 patients and other partially involved or fully involved in 33 patients. AChA territory spared or ischaemia restricted to MT only, compared with other partial infarct patterns or full infarct, was independently associated with good discharge outcome (44.4% vs 12.1%, OR 7.24, 95% CI 1.32 to 39.89, p=0.023).
In acute ICA occlusion, the absence of AChA infarction or restriction to the MT is an independent predictor of good discharge outcome. Analysis of AChA infarct patterns may improve early prognostication and decision-making.
Journal of neurology, neurosurgery, and psychiatry 04/2012; 83(6):586-90. · 4.87 Impact Factor
[show abstract][hide abstract] ABSTRACT: Type 2 diabetes rates in the general population have risen with the growing obesity epidemic. Knowledge of temporal patterns and factors associated with comorbid diabetes among stroke patients may enable health practitioners and policy makers to develop interventions aimed at reducing diabetes rates, which may consequently lead to declines in stroke incidence and improvements in stroke outcomes.
Using the Nationwide Inpatient Sample (NIS), a nationally representative data set of US hospital admissions, we assessed trends in the proportion of acute ischemic stroke (AIS) patients with comorbid diabetes from 1997 to 2006. Independent factors associated with comorbid diabetes were evaluated using multivariable logistic regression.
Over the study period, the absolute number of AIS hospitalizations declined by 17% (from 489,766 in 1997 to 408,378 in 2006); however, the absolute number of AIS hospitalizations with comorbid type 2 diabetes rose by 27% [from 97,577 (20%) in 1997 to 124,244 (30%) in 2006, p < 0.001]. The rise in comorbid diabetes over time was more pronounced in patients who were relatively younger, Black or 'other' race, on Medicaid, or admitted to hospitals located in the South. Factors independently associated with higher odds of diabetes in AIS patients were Black or 'other' versus White race, congestive heart failure, peripheral vascular disease, history of myocardial infarction, renal disease and hypertension.
Although hospitalizations for AIS in the US decreased from 1997 to 2006, there was a steep rise in the proportion with comorbid diabetes (from 1 in 5 to almost 1 in 3). Specific patient populations may be potential targets for mitigating this trend.