Independent Predictors of Perioperative Stroke-Related Mortality after Cardiac Surgery

Background and Purpose: Perioperative stroke remains a devastating complication after cardiac surgery and is associated with significant morbidity and mortality. Despite the significant contribution of stroke to perioperative mortality, risk factors for perioperative stroke-related mortality have not been well characterized. Our aim was to identify independent predictors of perioperative stroke-related mortality after cardiac surgery, using the Pennsylvania Health Care Cost Containment Council (PHC4) database which provides information on cause of death. Methods: We retrospectively examined patient medical records from 2012 to 2014 of 3345 patients (ages 18-99) who underwent a cardiac surgical procedure and suffered perioperative (30-day) mortality. Perioperative stroke-related mortality was identified by International Classification of Diseases, Tenth Revision, Clinical Modification cause of death codes. We performed Fisher's exact test and multivariate analysis to identify comorbidities that independently predict perioperative stroke-related mortality. Results: After controlling for all variables with multivariate analysis, we found that patients with carotid stenosis were 4.9 (adjusted odds ratio [aOR], 95% confidence interval [CI] 1.8-12.8) times more likely to die from a stroke than from other causes, when compared to patients without carotid stenosis. Other independent predictors of perioperative stroke-related mortality included in-hospital stroke (aOR 108.8, 95%CI 48.2-245.9), history of stroke (aOR 17.1, 95%CI 3.3-88.4), and age ≥ 80 (aOR 4.9, 95%CI 2.1-11.2). Conclusions: This is the first study to establish carotid stenosis, among other comorbidities, as an independent predictor of perioperative stroke-related mortality after cardiac surgery. Understanding risk factors for mortality from stroke will help enhance the efficacy of preoperative screening, intraoperative neurophysiological monitoring, and potential treatments for stroke. Interventions to manage carotid stenosis and other identified risk factors prior to, during, or immediately after surgery may have the potential to reduce perioperative stroke-related mortality after cardiac surgery.     

Prognostic significance of admission levels of troponin I in patients with acute ischaemic stroke

OBJECTIVES: Successful prediction of cardiac complications early in the course of acute ischaemic stroke could have an impact on the clinical management. Markers of myocardial injury on admission deserve investigation as potential predictors of poor outcome from stroke. METHODS: We prospectively investigated 330 consecutive patients with acute ischaemic stroke admitted to our emergency department based stroke unit. We analysed the association of baseline levels of cardiac troponin I (cTnI) with (a) all-cause mortality over a six month follow up, and (b) in-hospital death or major non-fatal cardiac event (angina, myocardial infarction, or heart failure). RESULTS: cTnI levels on admission were normal (lower than 0.10 ng/ml) in 277 patients (83.9%), low positive (0.10-0.39 ng/ml) in 35 (10.6%), and high positive (0.40 ng/ml or higher) in 18 (5.5%). Six month survival decreased significantly across the three groups (p<0.0001, log rank test for trend). On multivariate analysis, cTnI level was an independent predictor of mortality (low positive cTnI, hazard ratio (HR) 2.14; 95% CI 1.13 to 4.05; p = 0.01; and high positive cTnI, HR 2.47; 95% CI 1.22 to 5.02; p = 0.01), together with age and stroke severity. cTnI also predicted a higher risk of the combined endpoint "in-hospital death or non-fatal cardiac event". Neither the adjustment for other potential confounders nor the adjustment for ECG changes and levels of CK-MB and myoglobin on admission altered these results. CONCLUSIONS: cTnI positivity on admission is an independent prognostic predictor in acute ischaemic stroke. Whether further evaluation and treatment of cTnI positive patients can reduce cardiac morbidity and mortality should be the focus of future research.     

Comparison of the impact of atrial fibrillation on the risk of early death after stroke in women versus men

BACKGROUND: Atrial fibrillation (AF) is considered a predictive factor of poor clinical outcome in patients with an ischemic stroke (IS). This study addressed whether the impact of AF on the in-hospital mortality after first ever IS is different according to the patient's gender. METHODS: We prospectively studied 1678 patients with first ever IS consecutively admitted to two University Hospitals. We recorded demographic data, vascular risk factors, and the stroke severity (NIHSS) at admission analyzing their impact on the in-hospital mortality and on the combined mortality-dependency at discharge using a Cox proportional hazards model. Two variable interactions between those factors independently related to in-hospital mortality and combined mortality-dependency at discharge were tested. RESULTS: Overall in-hospital mortality was 11.3%. Cox proportional hazards model showed that NIHSS at admission (HR: 1.178 [95% CI 1.149-1.207]), age (HR: 1.044 [95% CI 1.026-1.061]), AF (HR: 1.416 [95% CI 1.048-1.913]), male gender (HR: 1.853 [95% CI 1.323-2.192) and ischemic heart disease (HR: 1.527 [95% CI 1.063-2.192]) were independent predictors of in-hospital mortality. A significant interaction between gender and AF was found (p = 0.017). Data were stratified by gender, showing that AF was an independent predictor of poor outcome just for woman (HR: 2.183 [95% CI 1.403-3.396]; p < 0.001). The independent predictors of combined mortality-disability at discharge were NIHSS at admission (HR: 1.052 [95% CI 1.041-1.063]), age (HR: 1.011 [95% CI 1.004-1.018]), AF (HR: 1.197 [95% CI 1.031-1.390]), ischemic heart disease (HR: 1.222 [95% CI 1.004-1.488]), and smoking (HR: 1.262 [95% CI 1.033-1.541]). CONCLUSIONS: The impact of AF is different in the two genders and appears as a specific ischemic stroke predictor of in-hospital mortality just for women.     

Carotid artery disease and perioperative stroke risk after surgical aortic valve replacement: A nationwide inpatient sample analysis

To study the role of carotid stenosis (CS) and cerebrovascular disease as independent risk factors for perioperative stroke following surgical aortic valve replacement (SAVR). The National Inpatient Sample (NIS) database was used for our study. All patients who underwent SAVR from 1999 to 2011 were identified using ICD-9 codes. Univariate and multivariate analysis of baseline characteristics, Elixhauser comorbidities and other covariates were examined to identify independent predictors of perioperative strokes following SAVR. Data on 50,979 patients who underwent SAVR from 1999 to 2011 was obtained. The mean age of the study cohort was 60.5. The study patients were predominantly Caucasian (79.3%) and males (60.01%). The incidence of perioperative stroke was 2.48%. CS (OR 1.8, 95%CI 1.1–2.8, p = 0.009) and cerebral arterial occlusion (OR 3.4, 95% CI 1.3–8.9) significantly increased perioperative stroke risk following SAVR. Infective endocarditis (OR 4.6, 95%CI 3.8–5.6, p = 0.00) and neurological disorders (OR 4.8, 95% CI 4–5.8, p = 0.00) appeared to be the strongest risk factors for strokes. Other risk factors found to be significant predictors of perioperative strokes (p < 0.05) were – age, higher VWR scores, CS, cerebral arterial occlusion, infective endocarditis, DM, HTN, renal failure, neurological disorders, coagulopathy and hypothyroidsm. In conclusion, perioperative stroke risk has remained more or less constant despite advancements in surgical techniques with risk having gone up in patients <65 years of age. CS and cerebral arterial occlusion significantly increase stroke risk following SAVR. Improved patient selection with pre-operative risk stratification and institution of preventive strategies are necessary to improve operative outcomes following SAVR.     

In-Hospital and Long-Term Prognosis after Spontaneous Intracerebral Hemorrhage among Young Adults Aged 18-65 Years

Background: Spontaneous intracerebral hemorrhage (ICH) accounts for 10%-15% of all strokes and has an estimated annual incidence of 5/100,000 in young adults. Limited data on prognosis after ICH in young adults are available. We aimed to identify prognostic predictors after ICH among adults aged 18-65 years. Methods: We retrospectively selected all patients with ICH from a prospective single-center registry of adults with first stroke before 65 years between 1997 and 2002. We recorded in-hospital mortality as well as mortality and recurrent stroke after discharge until December 1, 2018. For in-hospital analysis, we compared patients that died in-hospital versus patients discharged alive. For long-term analysis, we compared patients that died in follow-up versus patients still alive. Independent prognostic predictors were identified using multivariate analyses. Results: Among 161 patients included, 24 (14.9%) died in-hospital. Among in-hospital survivors, 5-year survival was 92.0%, 10-year survival 78.1%, and 15-year survival 62.0%. After median follow-up of 17 years, 47.4% of patients died, 18 patients had ischemic stroke, and 6 recurrent ICH. Regarding in-hospital prognosis, coma at admission (OR .02 [.00-.11]) was independent predictor for mortality whereas alcoholic habits (OR 12.32 [1.82-83.30]) was independent predictor for survival. An increasing age (OR 1.08 [1.03-1.12]), higher blood glucose levels (OR 1.01 [1.00-1.01]), and hypertension (OR 2.21 [1.22-4.00]) were independent predictors of long-term mortality after ICH. Conclusions: Alcoholic habits may influence in-hospital survival after ICH in young adults. Long-term mortality in young adults seems to be lower than in elderly and was predicted by higher blood glucose levels and hypertension.     

院内缺血性卒中的诊疗现状与挑战

院内卒中是指因其他疾病住院的患者在住院期间发生的急性卒中,其中最常见的类型是缺血性卒中.与社区卒中相比,院内缺血性卒中的危险因素和发病机制更为复杂,除了栓塞、低灌注、高凝状态,医源性因素也是重要的致病原因之一.院内缺血性卒中患者的不良功能预后和死亡率均较社区患者显著增高,研究提示基础疾病较多、围手术期栓塞所致脑梗死范围...     

Prognostic value of very early seizures for in-hospital mortality in atherothrombotic infarction

We studied the influence of very early seizures (within 48 h of stroke onset) on in-hospital mortality in a cohort of 452 consecutive patients with atherothrombotic infarction. These patients were selected from 2000 consecutive acute stroke patients registered in a prospective hospital-based stroke registry in Barcelona, Spain. A comparison of data between the nonseizure (n = 442) and seizure (n = 10) groups was made. Predictors of very early seizures were assessed by multivariate analysis. The in-hospital mortality rate was significantly higher in atherothrombotic stroke patients with very early seizures than in those without seizures (70 vs. 19.5%, p < 0.001). Independent predictors of in-hospital mortality included very early seizures, congestive heart failure, atrial fibrillation, 85 years of age or older, altered consciousness, dizziness, parietal and pons involvement, and respiratory and cardiac complications. After multivariate analysis, atherothrombotic infarction of occipital topography and decreased consciousness appeared to be independent predictors of atherothrombotic stroke with very early seizures. Very early seizures constitute an important risk factor for in-hospital mortality after atherothrombotic stroke.     

Trends in hospitalized stroke for blacks and whites in the United States, 1980-1999

BACKGROUND: Racial differences in stroke mortality are widely recognized, but it is unclear whether or not these differences are due mainly to blacks having a greater stroke incidence or higher case fatality rates compared to those of whites. OBJECTIVES: The aim of this study was to describe the race-specific US trends in hospital discharge rates and in-hospital mortality among stroke patients for the period 1980-1999. It was hypothesized that the hospital discharge rates and in-hospital mortality among stroke patients would be greater for blacks than for whites. METHODS: Data from the National Hospital Discharge Survey for the period 1980-1999 were used to identify stroke subjects according to the codes of the International Classification of Diseases, ninth revision (codes 430-434 and 436). Direct standardization and Poisson regression were used to compare hospitalized stroke morbidity and mortality rates between blacks and whites. The main outcome measures were the number of stroke discharges and in-hospital deaths for black and white stroke patients. RESULTS: Between the years 1980 and 1999, the hospital discharge rates for stroke increased for blacks (n = 8,700) and decreased for whites (n = 46,154); the in-hospital mortality rates decreased for both black and white stroke patients. Generally, the risk of a stroke hospitalization was greater for blacks than for whites by more than 70%, whereas both groups were similar in terms of in-hospital mortality rates among stroke patients. CONCLUSIONS: Differences between blacks and whites in terms of stroke mortality are more likely due to differences in stroke incidence rather than case fatality. These data imply that greater attention should be given to primary/secondary prevention and that additional research is needed to understand the reasons for these patterns.     

An Asian Perspective on Gender Differences in In-Hospital and Long-Term Outcome of Cardiac Mortality and Ischemic Stroke after Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

ObjectivesGender differences historically exist in cardiovascular disease, with women experiencing higher rates of major adverse cardiovascular events. We investigated these trends in a contemporary Asian cohort, examining the impact of gender differences on cardiac mortality and ischemic stroke after primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI).Materials and MethodsWe analysed 3971 consecutive patients who underwent primary PCI for STEMI retrospectively. The primary outcome was cardiac mortality and ischemic stroke in-hospital, at one year and on longer-term follow up (median follow up 3.62 years, interquartile range 1.03–6.03 years).ResultsThere were 580 (14.6%) female patients and 3391 (85.4%) male patients. Female patients were older and had higher prevalence of hypertension, diabetes, previous strokes, and chronic kidney disease. Cardiac mortality was higher in female patients during in-hospital (15.5% vs. 6.2%), 1-year (17.4% vs. 7.0%) and longer term follow up (19.9% vs. 8.1%, log-rank test: p < 0.001). Similarly, females had higher incidence of ischemic stroke at in-hospital (2.6% vs. 1.0%), 1-year (3.6% vs. 1.4%) and in the longer-term (6.7% vs. 3.1%) as well (log-rank test: p < 0.001). Female gender remained an independent predictor of in-hospital cardiac mortality (HR 1.395, 95%CI 1.061-1.833, p=0.017) and on longer-term follow-up (HR 1.932 95%CI 1.212-3.080, p=0.006) even after adjusting for confounders.ConclusionsFemales were at higher risk of in-hospital and long-term cardiac mortality and ischemic stroke after PPCI for STEMI. Future studies are warranted to investigate the role of aggressive management of cardiovascular risk factors and follow-up to improve outcomes in the females with STEMI.     

Association between hyperglycemia, heart failure and mortality in stroke patients

Background:  Acute hyperglycemia predicts increased mortality after stroke. The aim of our study was to determine if acute stroke patients with hyperglycemia suffer from increased rate of in-hospital adverse events which could influence survival such as pneumonia, heart failure and myocardial infarction.
Methods:  In a retrospective study with prospective follow-up, 689 patients with first-ever ischaemic stroke and high frequency of cardiovascular diseases were eligible. Follow-up period was 1–7 years (14 308 person-months).
Results:  The frequency of in-hospital heart failure and nosocomial pneumonia was the highest in patients without pre-hospital diagnosis of diabetes mellitus and with fasting glucose ≥7 mmol/l (50% and 20.2%, respectively) and the lowest in patients without pre-hospital diagnosis of diabetes and fasting glucose ≤6.1 mmol/l (12.3% and 8.1%). On multivariate analysis fasting glucose was significantly associated with risk of in-hospital heart failure (OR: 1.12, 95% CI: 1.01–1.23), but not with pneumonia. Glucose level was an independent predictor of mortality only when statistical model did not include heart failure as a variable.
Conclusions:  In stroke patients with hyperglycermia increased rate of heart failure could be responsible for higher mortality.     

The Prevalence and Impact of Status Epilepticus Secondary to Intracerebral Hemorrhage: Results from the US Nationwide Inpatient Sample

Background

Status epilepticus (SE) has been identified as a predictor of morbidity and mortality in many acute brain injury patient populations. We aimed to assess the prevalence and impact of SE after intracerebral hemorrhage (ICH) in a large patient sample to overcome limitations in previous small patient sample studies.

Methods

We queried the Nationwide Inpatient Sample for patients admitted for ICH from 1999 to 2011, excluding patients with other acute brain injuries. Patients were stratified into SE diagnosis and no SE diagnosis cohorts. We identified independent risk factors for SE and assessed the impact of SE on morbidity and mortality with multivariable logistic regression models. Logistic regression was used to evaluate the trend in SE diagnoses over time as well.

Results

SE was associated with significantly increased odds of both mortality and morbidity (odds ratios (OR) 1.18 [confidence intervals (CI) 1.01–1.39], and OR 1.53 [CI 1.22–1.91], respectively). Risk factors for SE included female sex (OR 1.17 [CI 1.01–1.35]), categorical van Walraven score (vWr 5–14: OR 1.68 [CI 1.41–2.01]; vWr > 14: OR 3.77 [CI 2.98–4.76]), sepsis (OR 2.06 [CI 1.58–2.68]), and encephalopathy (OR 3.14 [CI 2.49–3.96]). Age was found to be associated with reduced odds of SE (OR 0.97 [CI 0.97–0.97]). From 1999 to 2011, prevalence of SE diagnosis increased from 0.25 to 0.61% (p < 0.001). Factors associated with SE were female sex, medium and high risk vWr score, sepsis, and encephalopathy. Independent predictors associated with increased mortality from SE were increased age, pneumonia, myocardial infarction, cardiac arrest, and sepsis.

Conclusions

SE is a significant, likely underdiagnosed, predictor of morbidity and mortality after ICH. Future studies are necessary to better identify which patients are at highest risk of SE to guide resource utilization.

     

Charlson comorbidity index as a predictor of in-hospital death in acute ischemic stroke among very old patients: a single-cohort perspective study

Chronic diseases are increasing worldwide. Association of two or more chronic conditions is related with poor health status and reduced life expectancy, particularly among elderly patients. Comorbidities represent a risk factor for adverse events in several critical illnesses. We aimed to evaluate if elderly patients are affected by multiple chronic pathologies, assessed by Charlson comorbidity index (CCI), showed a reduced in-hospital survival after ischemic stroke. In a 3-year period, we evaluated all the subjects admitted to our internal medicine department for ischemic stroke. Age, sex, NIHSS score and all the comorbidities were recorded. Days of hospitalization, hospital-related infections and in-hospital mortality were also assessed. For each patient, we evaluated CCI, obtaining four classes: group 1 (CCI: 2–3), group 2 (CCI: 4–5), group 3 (CCI: 6–7) and group 4 (CCI: ≥8). Survival was evaluated with Kaplan–Meier and Cox regression analyses. The complete model considered in-hospital death as the main outcome, days of hospitalization as the time variable and CCI as the main predictor, adjusting for NIHSS, sex and nosocomial infections. Patients in CCI group 3 and 4 had an increased risk of in-hospital mortality, independently of NIHSS, sex and nosocomial infections. Elderly patients with multiple comorbidities have higher risk of in-hospital death when affected by ischemic stroke.     

COVID-19 and Stroke: Incidence and Etiological Description in a High-Volume Center

BackgroundAn increased rate of thrombotic events has been associated to Coronavirus Disease 19 (COVID-19) with a variable rate of acute stroke. Our aim is to uncover the rate of acute stroke in COVID-19 patients and identify those cases in which a possible causative relationship could exist.MethodsWe performed a single-center analysis of a prospective mandatory database. We studied all patients with confirmed COVID-19 and stroke diagnoses from March 2^nd to April 30^th. Demographic, clinical, and imaging data were prospectively collected. Final diagnosis was determined after full diagnostic work-up unless impossible due to death.ResultsOf 2050 patients with confirmed SARS-CoV-2 infection, 21 (1.02%) presented an acute ischemic stroke 21 and 4 (0.2%) suffered an intracranial hemorrhage. After the diagnostic work-up, in 60.0% ischemic and all hemorrhagic strokes patients an etiology non-related with COVID-19 was identified. Only in 6 patients the stroke cause was considered possibly related to COVID-19, all of them required mechanical ventilation before stroke onset. Ten patients underwent endovascular treatment; compared with patients who underwent EVT in the same period, COVID-19 was an independent predictor of in-hospital mortality (50% versus 15%; Odds Ratio, 6.67; 95% CI, 1.1-40.4; p 0.04).ConclusionsThe presence of acute stroke in patients with COVID-19 was below 2% and most of them previously presented established stroke risk factors. Without other potential cause, stroke was an uncommon complication and exclusive of patients with a severe pulmonary injury. The presence of COVID-19 in patients who underwent EVT was an independent predictor of in-hospital mortality.     

The beneficial effect of statins treatment by stroke subtype

Background and purpose:  Statins have shown some protective effect after ischaemic stroke in observational studies. However, this effect has never been assessed by etiological subtypes.
Methods:  Observational study using data from the Stroke Unit Data Bank from consecutive patients with cerebral infarction. Variables analyzed: demographic data, cardiovascular risk factors, treatment with statins at stroke onset, stroke severity, stroke subtype, in-hospital complications, length of stay, and functional status at discharge (modified Rankin Scale).
Results:  A total of 2742 patients were included, 1539 were men. Mean age was 69.17 years (SD 12.19). Of these, 281 patients (10.2%) were receiving statins when admitted. The logistic regression analyses showed that previous treatment with statins was an independent predictor for better outcome at discharge among all strokes (OR, 2.08; 95% CI, 1.39 to 3.1) as well as for the atherothrombotic (OR, 2.79; 95% CI, 1.33 to 5.84) and lacunar strokes (OR, 2.28; 95% CI, 1.15 to 4.52) after adjustment for demographic data, risk factors, previous treatments, stroke subtypes, stroke severity, in-hospital complications and length of stay. This benefit was not observed either in cardioembolic or in other etiology strokes.
Conclusions:  Previous treatment with statins is an independent factor associated with good outcomes in patients with ischaemic stroke. Atherothrombotic and small vessel strokes show the greatest benefit.     

Cerebral Microbleeds are Associated with Higher Mortality Among Ischemic Stroke Patients

Background

Several studies have shown that cerebral microbleeds (CMBs) increase the risk of long-term stroke-related mortality. The purpose of this study was to determine if the existence and burden of CMBs are a predictor of in-hospital death among patients with acute ischemic stroke (AIS).

Family history associated with improved functional outcome following ischemic stroke

BACKGROUND: Few studies to date have documented genetic influences on outcomes of hospitalization among patients with acute ischemic stroke. OBJECTIVE: To assess the influence of the family history of stroke on in-hospital mortality and hospitalization outcome among patients having acute ischemic stroke. METHODS: The medical records for 916 consecutive adult patients admitted for acute ischemic stroke during 12/1/2001-2/28/2002 at 34 randomly selected Georgia hospitals were centrally abstracted. The patients were classified as having a positive family history of stroke or not. The two groups were compared on risk factors, comorbidities, admission characteristics, hospital disposition status, and outcome measures. Multivariate logistic regression was used to assess the independent contributions of important variables identified by univariate screening. RESULTS: A positive family history of stroke was significantly associated with a decreased frequency of medical history of coronary artery disease, a decreased frequency of medical history of congestive heart failure, an increased frequency of medical history of hypertension, and younger age among patients with acute ischemic stroke who were 18 years or older. The family history was not associated with in-hospital mortality (odds ratio 1.49, 95% confidence interval 0.79-2.80 for incident cases). The interaction of family history and age was significantly associated with discharge destination and discharge functional status. CONCLUSIONS: Preliminary analyses found associations between family history and stroke outcome. The role of a family history of stroke in stroke outcome merits further study.     

Association of underlying untreated cardiovascular risk factors with mortality and functional outcome in ischaemic stroke patients

ObjectivesThe study aimed to determine the prevalence of untreated pharmacologically modifiable cardiovascular risk factors (PMRF) among patients with ischaemic stroke and the association with in-hospital mortality and functional outcome.MethodsWe analysed the data from ischaemic stroke cases admitted to Sarawak General Hospital between June 2013 and June 2021. We matched the underlying PMRFs with prior medications and categorised them as treated, untreated, or no PMRF. We calculated the prevalence and assessed the association between untreated PMRFs and in-hospital mortality or favourable functional outcome (FFO) at discharge, which was adjusted for age, sex, and other covariates in multivariable models.ResultsWe included 1963 patients [65.4% male, 59.8 (SD 13.4) years]; 43.8% who had at least one untreated PMRF had triple the odds of in-hospital mortality [adjusted OR (aOR) 2.86, (95%CI 1.44, 5.70)], whereas 30.2% who had all PMRFs treated showed no significant association. Untreated hypertension [aOR 2.19 (95%CI 1.21, 3.98)], treated [aOR 3.02 (95%CI 1.32, 6.92)], and untreated atrial fibrillation [aOR 1.89 (95%CI 1.18, 3.03)] were significantly associated with more in-hospital death, whereas treated prior stroke was associated with fewer in-hospital death [aOR 0.31 (95%CI 0.11, 0.84)]. Treated diabetes [aOR 0.66 (95%CI 0.49, 0.88)] and untreated prior stroke [aOR 0.53 (95%CI 0.33, 0.83)] were associated with fewer FFO.ConclusionThe high prevalence of untreated underlying PMRFs was significantly associated with poorer outcomes among Malaysian patients with ischaemic stroke in Sarawak. Efforts are needed to promote early screening and treatment of cardiovascular risk factors to reduce the burdens and improve stroke outcomes in this region.     

Clinical Outcomes and Costs of Recurrent Ischemic Stroke: A Systematic Review

ObjectiveRecurrent stroke patients suffer significant morbidity and mortality, representing almost 30% of the stroke population. Our objective was to determine the clinical outcomes and costs of recurrent ischemic stroke (recurrent-IS).MethodsOur study protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020192709). Following PRISMA guidelines, our medical librarian conducted a search in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL (last performed on August 25, 2020). Inclusion criteria: (1) Studies reporting clinical outcomes and/or costs of recurrent-IS; (2) Original research published in English in year 2010 or later; (3) Study participants aged ≥18 years. Exclusion criteria: (1) Case reports/studies, abstracts/posters, Editorial letters/reviews; (2) Studies analyzing interventions other than intravenous thrombolysis and thrombectomy. Four independent reviewers selected studies with review of titles/abstracts and full-text, and performed data extraction. Discrepancies were resolved by a senior independent arbitrator. Risk-of-bias was assessed using the Mixed Methods Appraisal Tool.ResultsInitial search yielded 20,428 studies. Based on inclusion/exclusion criteria, 9 studies were selected, consisting of 24,499 recurrent-IS patients. In 5 studies, recurrent-IS ranged from 4.4-56.8% of the ischemic stroke cohorts at 3 or 12 months, or undefined follow-up. Mean age was 60-80 years and female proportions were 38.5-61.1%. Clinical outcomes included mortality 11.6-25.9% for in-hospital, 30-days, or 4-years (3 studies). In one study from the U.S., mean in-hospital costs were $17,121(SD-$53,693) and 1-year disability costs were $34,639(SD-$76,586) per patient.ConclusionsOur study highlights the paucity of data on clinical outcomes and costs of recurrent-IS and identifies gaps in existing literature to direct future research.     

Diabetes mellitus,insulin resistance,hyperglycemia, and stroke

It is well established that diabetes is associated with an increased risk of stroke. Once a stroke has occurred, patients with diabetes experience poorer outcomes (functional status, mortality). Convincing data now support aggressive glucose control and comprehensive cardiovascular risk factor management to prevent stroke in patients with diabetes. However, there remains a distinct paucity of information concerning secondary stroke prevention. Hyperglycemia in the acute stroke setting is a marker for poor outcomes, but it remains unclear whether intensive in-hospital lowering of blood glucose levels improves clinical outcomes. Targeting insulin resistance as a modifiable risk factor for stroke is a novel strategy currently under investigation.