Spectrum of superficial posterior cerebral artery territory infarcts

Posterior cerebral artery (PCA) territory infarction is not uncommon. Published series were concentrated either on isolated deep PCA territory infarcts or on incomplete calcarine artery territory infarcts. Although, correlations between clinical symptoms, causes of stroke and outcome at 6-months in patients with superficial PCA territory stroke are less well known. We sought prospectively stroke causes, infarct topography, and clinical findings of 137 patients with superficial PCA territory infarcts with or without mesencephalic/thalamic involvement, representing 11% of patients with posterior circulation ischemic stroke in our Stroke Registry. We analyzed patients by subdividing into three subgroups; (1). cortical infarct (CI) group; (2). cortical and deep infarcts (CDI) (thalamic and/or mesencephalic involvement) group; (3). bilateral infarcts (BI) group. We studied the outcomes of patients at 6-month regarding clinical findings, risk factors and vascular mechanisms by means of comprehensive vascular and cardiac studies. Seventy-one patients (52%) had cortical (CI) PCA infarct, 52 patients (38%) had CDI, and 14 patients (10%) had bilateral PCA infarct (BI). In the CDI group, unilateral thalamus was involved in 38 patients (73%) and unilateral mesencephalic involvement was present in 27% of patients. The presumed causes of infarction were intrinsic PCA disease in 33 patients (26%), proximal large-artery disease (PLAD) in 33 (24%), cardioembolism in 23 (17%), co-existence of PLAD and cardioembolism in 7 (5%), vertebral or basilar artery dissection in 8 (6%), and coagulopathy in 2. The death rate was 7% in our series and stroke recurrence was 16% during 6-month follow-up period. Features of the stroke that was associated with significant increased risk of poor outcome included, consciousness disturbances at stroke onset (RR, 66.6; 95% CI, 8.6-515.5), mesencephalic and/or thalamic involvement (RR, 3.79; 95% CI, 1.49-9.65), PLAD (RR, 2.71; 95% CI, 1.09-6.73), and basilar artery disease (RR, 5.94; 95% CI, 1.73-20.47). The infarct mechanisms in three different types of superficial PCA territory stroke were quite similar, but cardioembolism was found more frequent in those with cortical PCA territory infarction. Although, the cause of stroke could not reliably dictate the infarct topography and clinical features. Visual field defect was the main clinical symptom in all groups, but sensorial, motor and neuropsychological deficits occurred mostly in those with CDI. Outcome is good in general, although patients having PLAD and basilar artery disease had more risk of stroke recurrence and poor outcome rather than those with intrinsic PCA disease.     

Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit

Dysphagia increases the risk of pneumonia in stroke patients. This study aimed to evaluate bedside swallowing screening for prevention of stroke-associated pneumonia (SAP) in acute stroke patients admitted to the intensive care unit (ICU). Consecutive acute stroke patients admitted to the stroke ICU from May 2006 to March 2007 were included. Patients were excluded if they were intubated on the first day of admission or had a transient ischemic attack. A 3-Step Swallowing Screen was introduced since October 2006 and therefore patients were divided into pre-screen and post-screen groups. A binary logistic regression model was used to determine independent risk factors for SAP and in-hospital death. There were 74 and 102 patients included in the pre- and post-screen groups, respectively. Pneumonia was associated with higher National Institutes of Health Stroke Scale (NIHSS) score, older age, nasogastric and endotracheal tube placement. After adjusting for age, gender, NIHSS score and nasogastric and endotracheal tube insertion, dysphagia screening was associated with a borderline decrease in SAP in all stroke patients (odds ratio, 0.42; 95% CI, 0.18-1.00; p=0.05). However, dysphagia screening was not associated with reduction of in-hospital deaths. Systematic bedside swallowing screening is helpful for prevention of SAP in acute stroke patients admitted to the ICU.     

重症缺血性脑卒中预后相关影响因素分析

目的探讨影响重症缺血性脑卒中(sIS)短期预后的相关因素。方法回顾性分析143例缺血性脑卒中(IS)住院患者的一般资料和实验室检查,包括既往史、血常规、血生化、凝血象等指标,头颅CT或MRI影像资料,发病后的并发症。根据美国国立卫生研究院卒中量表(NIHSS)评分变化进行病情严重程度分类及预后判断。结果 143例IS患者中sIS者82例(57.3%),轻症缺血性脑卒中(mIS)61例(42.7%)。82例sIS患者中,预后不良的发生率为73.2%(60/82)。sIS预后改善与预后不良组间入院收缩压、低密度脂蛋白(LDL-C)、随机血糖(Glu)比较差异有统计学意义(P<0.05);多因素Logistic回归分析显示,LDL-C水平升高是sIS早期不良预后的独立危险因素(OR=1.68,95%CI:1.05～2.69),入院时收缩压相对升高对sIS的预后具有保护作用(OR=0.97,95%CI:0.05～1.00)。mIS 30d预后不良组与sIS 30d预后不良组间房颤、卒中相关肺炎(SAP)、血白细胞数升高比较有统计学差异(P<0.05);多因素Logistic回归分析显示,房颤(OR=5.04,95%CI:1.31～9.63)、SAP(OR=3.23,95%CI:1.12～9.36)是IS早期不良预后的独立危险因素。结论房颤、LDL-C水平升高、SAP是IS早期预后不良的独立危险因素。     

Influence of prestroke dementia on early and delayed mortality in stroke patients

Causes of early and delayed death after stroke differ. It has been suggested that delayed mortality rate was increased in patients with post-stroke dementia. Prestroke dementia is frequent: its influence on survival in stroke patients has never been evaluated. The aim of this study was to evaluate the influence of prestroke dementia on early and delayed mortality rate after stroke. In a cohort of 202 consecutive stroke patients aged ≥ 40 years admitted between November 1995 and May 1996 in a primary care center, the prevalence of prestroke dementia was determined using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) with a cut-off of 104. Patients were followed-up for 3 years. Statistics were performed using life-table methods. Of 202 patients, 33 had prestroke dementia. Of 142 survivors at month–6, 44 were demented, of them 15 having prestroke and 29 new-onset post-stroke dementia. No patient was lost to follow-up. The risk of death at month–6 was higher in patients with prestroke dementia (RR 2.7; 95 % CI: 1.6–4.8). However, independent predictors of early death were age, severity of the deficit at admission, type and etiology of stroke. The risk of delayed death was higher in patients with prestroke dementia (RR 4.97; 95 % CI: 1.76–13.98) as in patients with new-onset post-stroke dementia (RR 6.24; 95 % CI: 2.67–14.57), compared with non-demented patients. The mortality rate did not differ between patients with prestroke and new-onset post-stroke dementia. Dementia at month–6 was an independent predictor of delayed death (RR 5.7; 95 % CI: 2.4–13.4), with age and stroke recurrence. Causes of death did not differ between demented and non-demented patients. Dementia adversely influences vital outcome in stroke patients, perhaps partly because the therapeutic approach differs between demented and non-demented patients. Received: 5 September 2001, Received in revised form: 20 June 2002, Accepted: 26 June 2002 Correspondence to Hilde Hénon, MD, PhD     

Risk Factors and Outcomes of Stroke-Associated Pneumonia in Patients with Stroke and Acute Large Artery Occlusion Treated with Endovascular Thrombectomy

Background and PurposeStroke-associated pneumonia (SAP) often increases high hospital mortality, prolongs length of hospital stay, and has considerable economic impact on healthcare costs. We aimed to explore independent predictors of SAP in acute anterior large artery occlusion patients who treated with endovascular treatment (EVT).MethodsConsecutive patients with acute anterior large artery occlusion stroke who underwent EVT from the Nanjing Stroke Registry from January 2019 to January 2020 were identified retrospectively. Patients were divided into SAP group and Non-SAP group. In the univariate analysis, variables including demographics, clinical factors, labs, and EVT features were compared between the two groups. Then a multivariable logistic regression analysis was conducted to determine independent predictors of SAP.ResultsOne hundred and twelve patients were enrolled. Patients with SAP, compared to those without SAP, had lower modified treatment in cerebral infarction (mTICI) score 2b-3 rate (54.8% vs 85.2%; P = 0.001), higher asymptomatic intracerebral hemorrhage rate (48.4% vs 28.4%; P = 0.046), lower modified Rankin Scale (mRS) score 0–2 rate at 90days rate (9.7% vs 60.5%; P < 0.001), and higher mortality at 90days (38.7% vs 11.1%; P = 0.001). The independent predictors of SAP were dysphagia (Unadjusted Odds ratio[OR] 6.49, 95% Confidence interval[CI] 2.49–16.92; P = 0.02; Adjusted OR 3.59, 95% CI 1.19–10.83; P = 0.02), neutrophil-lymphocyte ratio (Unadjusted OR 1.19, 95% CI 1.1–1.3; P = 0.001; Adjusted OR 1.15, 95% CI 1.06–1.25; P = 0.001), and mTICI 2b-3 (Unadjusted OR 0.21, 95% CI 0.08–0.54; P = 0.001; Adjusted OR 0.3, 95% CI 0.1–0.92; P = 0.04).ConclusionDysphagia, higher neutrophil-lymphocyte ratio, and failed recanalization were associated with SAP in acute ischemic stroke patients underwent endovascular therapy. Identification and prevention of SAP was necessary and important.     

Effects of major adipokines and the −420 C > G resistin gene polymorphism on the long-term outcome of patients with acute ischemic stroke

Abstract

Aim: The association between adiponectin, leptin, and resistin and the long-term outcome of ischemic stroke are controversial. We aimed to evaluate this relationship.

Methods: We prospectively studied 83 patients consecutively hospitalized for acute ischemic stroke (38.6% males, age 79.7?±?6.3?years). Serum adiponectin, leptin, and resistin levels and the ?420C?>?G polymorphism of the resistin gene were determined at admission. Stroke severity at admission was evaluated with the National Institutes of Health Stroke Scale (NIHSS). One year after discharge, functional status, incidence of cardiovascular events and all-cause mortality were recorded. Functional status was evaluated with the modified Rankin scale (mRS).

Results: Patients with the G allele had lower mRS (p?<?.05) and patients with adverse outcome had higher serum resistin levels (p?<?.05). The only independent predictor of adverse outcome was mRS at discharge (risk ratio (RR) 2.78, 95% confidence interval (CI) 1.54–5.00; p?<?.001). Higher adiponectin levels were an independent predictor of cardiovascular morbidity (RR 1.07, 95% CI 1.01–1.14; p?<?.05). Patients who died had higher serum adiponectin levels than those who survived (p?<?.05). The only independent predictor of all-cause mortality was NIHSS at admission (RR 1.19, 95% CI 1.04–1.35; p?<?.01).

Conclusions: In patients with acute ischemic stroke, the G allele of the ?420C?>?G polymorphism of the resistin gene promoter is more frequent in those with a more favorable functional outcome at one year after discharge. Patients with higher serum resistin levels appear to have worse long-term functional outcome, while higher serum adiponectin levels are associated with higher incidence of cardiovascular events.     

Respiratory infectious complications after acute ischemic stroke]

BACKGROUND AND PURPOSE: Respiratory infection is a frequent complication in acute ischemic stroke, but it seems to have been made light of in stroke care. The purpose of this study is to examine the clinical characteristics of respiratory infectious complications in patients with acute ischemic stroke. METHOD: Two-hundred and fifty-eight consecutive patients (158 men, 100 women, 70.6 +/- 12.9 years old) with acute ischemic stroke were admitted to our hospitals between May and October in 1999. Age, gender, history of stroke, the severity of stroke on admission, stroke subtype (lacunar brain infarction, atherothrombotic brain infarction, cardioembolic brain infarction, and others), aspiration, naso-gastric tube feeding, vascular risk factors, the length of hospital stay and outcome of patients were noted. We compared them between patients with and without respiratory infections. RESULTS: Forty-five (17.4%) patients were developed respiratory infections. Cardioembolic stroke patients were more frequently developed respiratory infections (67%) compared with other stroke subtypes. The independent risk factors for respiratory infectious complications by multiple logistic regression model were the aspiration (OR, 5.513; 95% CI, 1.793-16.946) and the severity of stroke on admission (OR, 1.090; 95% CI, 1.034-1.150). Mortality of patients with respiratory infectious complications was as high as 24%, and all survivors discharged to another hospital. After adjustment for age and the severity of stroke, respiratory infection was one of the independent risk factors of poor stroke outcome (OR, 5.838; 95% CI, 1.792-19.018). CONCLUSION: Aspiration and the severity of stroke independently predict development of respiratory infectious complication in acute ischemic stroke. Respiratory infections may make worse their stroke outcome. A measure to infectious complications and aspiration needs to be taken for the patients suffering from severe ischemic stroke.     

Study on frequency and predictors of dementia after ischemic stroke

Abstract.Objective: We studied a large hospitalized cohort of patients aged 55 years and over with acute ischemic stroke to identify the frequency and predictors of poststroke dementia.Methods: A total of 434 consecutive patients with ischemic stroke were enrolled in this study. During admission, the demographic data, vascular risk factors, stroke features, and neurological status information were collected. All subjects were examined by a battery of neuropsychological tests during admission and 3 months after stroke. Logistic regression analysis was used to find the predictors of poststroke dementia.Results: (1) The frequency of poststroke dementia was 27.2%, that of stroke-related dementia was 21.6%, and that of dementia after first-ever stroke was 22.7% 3 months after stroke. (2) Univariate analysis indicated that older age, low educational level ( 6 years), everyday drinking, diabetes mellitus, atrial fibrillation, prior stroke, left carotid territory infarction, embolism, multiple stroke lesions, dysphasia, and gait impairment were more frequent in the patients with poststroke dementia. (3) Multivariate analyses demonstrated that age (OR 1.179, 95%CI 1.130–1.230), low educational level (OR 1.806, 95 %CI 1.024–3.186), everyday drinking (OR 3.447, 95 %CI 1.591–7.468), prior stroke (OR 2.531, 95 %CI 1.419–4.512), atrial fibrillation (OR 3.475, 95%CI 1.712–7.057), dysphasia (OR 5.873, 95 %CI 2.620–13.163), and left carotid territory infarction (OR 1.975, 95%CI 1.152–3.388) were associated with poststroke dementia.Conclusions: The frequency of dementia is about one-forth of patients with ischemic stroke 3 months after stroke. Independent predictors of poststroke dementia include age, low educational level, everyday drinking, prior stroke, dysphasia, atrial fibrillation, and left carotid territory infarction.Abrreviations AD Alzheimers disease - ADL Activity of Daily Living - CI Confidence Interval - CMMS Chinese version of the Mini-Mental State Examination - CT Computed Tomography - DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4th edition - FOM Fuld Object Memory Evaluation - IADL Instrumental Activity of Daily Living - IQCODE Informant Questionnaire on Cognitive Decline in the Elderly - MRI Magnetic Resonance Imaging - OR Odds Ratio - POD Pfeiffer Outpatient Disability Questionnaire - RVR Rapid Verbal Retrieve - SD Standard Error - TIA Transient Ischemic Attack     

Risk vs benefit of anti-thrombotic therapy in ischaemic stroke patients with cerebral microbleeds

Abstract Background   Retrospective studies suggested that cerebral microbleeds (MB) on magnetic resonance images (MRI) increase risk of intracerebral haemorrhage (ICH). Objective   To compare the benefit of anti-thrombotic agents in stroke prevention (absolute risk reduction 2.49 –6 %) versus risk of ICH in ischaemic stroke patients with MB. Materials and methods   We prospectively studied patients admitted consecutively for acute ischaemic stroke between 1999 and 2004. MB on MRI were documented. Primary end points were subsequent ICH, recurrent cerebral infarct (CI) and mortality. Results   A total of 908 patients were recruited. MB were identified in 252 (27.8 %) patients. Mean follow-up period was 26.6 ± 15.4 months. Risk of subsequent ICH increased significantly with quantity of MB: 0.6 % (no MB), 1.9 % (1 MB), 4.6 % (2–4 MB) and 7.6 % (≥ 5 MB) (p < 0.001). There was also a significant increase in mortality from ICH: 0.6 %, 0.9 %, 1.5 % and 3.8 % respectively (p = 0.054). Rate of recurrent CI was 9.6 %, 5.6 %, 21.5 % and 15.2 % respectively (p = 0.226). Mortality from CI and myocardial infarction did not increased with quantity of MB. Survival analyses showed that age, presence of MB, mixed cortical-subcortical distribution of MB were independent predictors of subsequent ICH. Conclusion   Risk and mortality of ICH increased with quantity of MB. As tendency to recurrent CI exceed that of ICH, anti-thrombotic agents are still warranted. However, in patients with ≥ 5 MB, the high risk and mortality of ICH seem to outweigh the modest benefit of antithrombotic agents. Extra precautions should be taken to minimize risk of ICH. Further studies in patients on Coumadin and assessment of functional outcome are warranted to support these preliminary findings.     

Clinical-diffusion mismatch defined by NIHSS and ASPECTS in non-lacunar anterior circulation infarction

Objectives Instead of the mismatch in MRI between the perfusion-weighted imaging (PWI) lesion and the smaller diffusion-weighted imaging (DWI) lesion (PWI-DWI mismatch), clinical-DWI mismatch (CDM) has been proposed as a new diagnostic marker of brain tissue at risk of infarction in acute ischemic stroke. The Alberta Stroke Program Early CT Score (ASPECTS) has recently been applied to detect early ischemic change of acute ischemic stroke. The present study applies the CDM concept to DWI data and investigated the utility of the CDM defined by the NIH Stroke Scale (NIHSS) and ASPECTS in patients with non-lacunar anterior circulation infarction. Methods Eighty-seven patients with first ever ischemic stroke within 24 hours of onset with symptoms of non-lacunar anterior circulation infarction with the NIHSS score ≥ 8 were enrolled. Initial lesion extent was measured by the ASPECTS on DWI within 24 hours, and initial neurological score was measured by the NIHSS. As NIHSS ≥ 8 has been suggested as a clinical indicator of a large volume of ischemic brain tissue, and the majority of patients with non-lacunar anterior infarction with score of NIHSS < 8 had lesions with ASPECTS ≥ 8 on DWI, so CDM was defined as NIHSS ≥ 8 and DWI-ASPECTS 8 ≥ . We divided patients into matched and mismatched patient groups, and compared them with respect to background characteristics, neurological findings, laboratory data, radiological findings and outcome. Results There were 35 CDM-positive patients (P group, 40.2%) and 52 CDM-negative patients (N group , 59.8%). P group patients had a higher risk of early neurological deterioration (END) than N group patients (37.1% vs 13.5%, p < 0.05), which were always accompanied by lesion growth defined by 2 or more points decrease on ASPECTS (36 to 72 hours after onset on CT). The NIHSS at entry were significantly lower in the P group, but there was no difference in the outcome at three months measured by the modified Rankin Scale. However, CDM was not an independent predictor of END by multiple logistic regression analysis. Conclusions Patients with CDM had high rate of early neurological deterioration and lesion growth. CDM defined as NIHSS ≥ 8 and DWI-ASPECTS ≥ 8 can be another marker for detecting patients with tissue at risk of infarction, but more work is needed to clarify whether this CDM method is useful in acute stroke management. Received in revised form: 30 July 2006