Outcome of first-ever acute ischemic stroke in the elderly

Our purpose was to evaluate the outcome of patients aged 70 years or older with a first-ever acute ischemic stroke and to identify the factors which determine poor outcome. Data from 115 patients, non-disabled prior to stroke, consecutively admitted to a medical department of a teaching hospital over a 30-month period, were prospectively collected at stroke onset and 6-month follow-up. Clinical and brain imaging findings and functional status were recorded. Predictors of unfavorable outcome at 6 months, defined as a modified Rankin Scale score >2, were analyzed by multiple logistic regression. The mean age of this cohort was 78.6 years (SD, 5.7) and 66.1% were women, 73.9% had hypertension, 25.2% diabetes, 36.0% atrial fibrillation (AF), 33.9% heart failure (HF), 15.8% previous transient ischemic attack (TIA), 47.8% a Charlson comorbidity index (CCI) score >1 and 52.2% a baseline National Institute of Health stroke scale (NIHSS) score ≥6. At 6 months, 54 patients (47%) had unfavorable outcome and the independent predictors of poor outcome were the initial systolic blood pressure and the NIHSS score on admission. In conclusion, near 50% of these old patients were dependent or dead 6 months after stroke onset and the main predictor of poor outcome was the neurological severity of stroke.     

Association between PRKCH gene polymorphisms and subcortical silent brain infarction

Recently, a large-scale genetic epidemiological study has shown significant association of single nucleotide polymorphisms (SNPs) in the protein kinase C η (PRKCH) gene with cerebral infarction, particularly, with lacunar infarction. To extend the findings, we tested association of two SNPs previously reported – rs3783799 and rs2230500 – in PRKCH with silent lacunar infarction (SLI), which has drawn substantial attention in the aging societies. Disease association was tested in the case–control study design. Subjects with and without SLI were recruited from people who underwent a health-screening examination including brain MRI. Two SNPs were genotyped and proven to be in complete linkage disequilibrium (D′ = 1.00, r² = 1.00) and thus showed comparable results of disease association, which were reproduced in two panels collected independently. In the entire population involving 295 cases and 497 controls, two SNPs remained to be significantly associated with SLI under a dominant model even after adjustment for confounding factors such as hypertension (e.g., genetic effects of rs2230500, P = 0.0026 for AA + AG vs. GG, adjusted odds ratio = 1.27; 95% CI, 1.09–1.48). As the two SNPs appear to be common only in Asian people, further replication study is warranted in the other Asian populations as well as the Japanese.     

Risk factors for first-ever acute ischemic non-embolic stroke in elderly individuals

BACKGROUND: Stroke is a leading cause of mortality and subsequent serious long-term physical and mental disability among survivors. In the elderly, ischemic stroke accounts for more than 80% of all strokes. OBJECTIVES: To identify major risk factors for a first-ever acute ischemic/non-embolic stroke in individuals older than 70 years. METHODS: A population-based case-control study of patients admitted to the University Hospital of Ioannina, Epirus, Greece, due to first-ever ischemic/non-embolic stroke from March 1997 to January 2002. All patients were subjected to brain CT and had their serum lipids and biochemical metabolic parameters determined within 24 h from the onset of symptoms. RESULTS: A total of 163 (aged>70 years) consecutive stroke patients and 166 apparently healthy volunteers were studied. An atherogenic lipid profile and metabolic disturbances were more prevalent in the patient group than in stroke-free controls. Multivariate logistic regression analysis identified diabetes mellitus (odds ratio (OR), 1.92; 95% CI, 1.02-3.63), triglycerides (TG) (OR, 1.16; 95% CI, 1.09-1.22), HDL-cholesterol (OR, 0.57; 95% CI, 0.43-0.76), apo A-I (OR, 0.80; 95% CI, 0.70-0.92), lipoprotein(a) [LP(a)] (OR, 1.51; 95% CI, 1.25-1.79), uric acid (OR, 1.30; 95% CI, 1.06-1.59) albumin (OR, 0.38; 95% CI, 0.20-0.70) fibrinogen (OR, 1.10; 95% CI, 1.05-1.13) and the metabolic syndrome (OR 2.48, 95% CI, 1.16-5.29) as significantly associated with ischemic/non-embolic stroke. CONCLUSION: Ischemic non-embolic stroke in the elderly is associated with dyslipidemia and several predictor metabolic factors, which could be substantially modified by lifestyle changes and therapeutic intervention.     

急性双侧脑梗死的病因分型及发病机制分析

目的探讨急性双侧脑梗死的病因分型及发病机制。方法选择经磁共振弥散加权成像(DWI)证实为急性双侧脑梗死的患者55例,根据梗死灶分布进行分组,双侧前循环梗死12例(前循环组),双侧后循环梗死28例(后循环组),一侧前循环合并对侧后循环梗死15例(合并组)。按照TOAST分型标准,分析不同病因及发病机制在各组的分布差异。结果 55例患者中,病因分型依次为大动脉粥样硬化42例,心源性栓塞9例,小动脉闭塞1例,其他和不明原因型3例。与后循环组比较,前循环组和合并组大动脉粥样硬化(21.4%、23.8%vs 54.8%)、心源性栓塞(33.3%、22.2%vs 44.4%)显著降低,差异有统计学意义(P<0.05)。发病机制依次为动脉-动脉栓塞20例,低灌注/栓子清除障碍15例,心源性栓塞9例,血栓形成4例,血管变异合并动脉-动脉栓塞4例,机制不明3例。与后循环组比较,前循环组和合并组动脉-动脉栓塞(10.0%、15.0%vs 75.0%),心源性栓塞(33.3%、22.2%vs44.4%)明显降低,而低灌注/栓子清除障碍(40.0%、46.7%vs 13.3%)明显升高,差异有统计学意义(P<0.05)。结论急性双侧脑梗死患者主要病因分型为大动脉粥样硬化和心源性栓塞,主要发病机制为动脉-动脉栓塞、心源性栓塞和低灌注。     

Frequency and significance of troponin T elevation in acute ischemic stroke

Elevated levels of troponin have been reported in patients with acute ischemic stroke. In this prospective study, the prevalence and characteristics of troponin elevation were examined in 244 patients with acute ischemic stroke but without overt ischemic heart disease. Troponin T (TnT) and creatine kinase-MB (CK-MB) concentrations were measured and 12-lead electrocardiograms obtained daily during the first 5 days of admission. Myocardial perfusion scintigraphy was performed in patients with TnT levels of 0.10 micro g/L and in comparable controls without elevation of TnT. Patients were followed for a mean of 19 +/- 7 months, with all-cause mortality as the clinical end point. Elevated levels of TnT (>0.03 micro g/L) and creatine kinase-MB (> or =10 micro g/L) were observed in 10% and 9% of patients, respectively. Patients with elevated TnT had higher frequencies of heart and/or renal failure. Perfusion abnormalities on myocardial perfusion scintigraphy at rest were not more frequent or pronounced in patients with TnT levels of > or =0.10 micro g/L than in the control group. Only 7 patients (3%) had elevations of TnT or creatine kinase-MB and electrocardiographic changes suggesting acute myocardial infarctions. According to univariate and multivariate analyses, elevation of TnT was significantly associated with mortality. In conclusion, elevated levels of TnT are rare in patients presenting with ischemic stroke but without overt ischemic heart disease. Heart and renal failure rather than myocardial infarction are the most likely causes. When present, elevation of TnT seems to be useful in identifying patients who are at increased risk of dying within the following 2 years.     

无症状脑梗死的临床意义

无症状脑梗死 (ｓｉｌｅｎｔｂｒａｉｎｉｎｆａｒｃｔｉｏｎ ,ＳＢＩ)是指无卒中病史 ,无明确神经系统定位体征 ,由影像学或尸检发现的梗死灶 ,包括 2种情况 :一是无卒中史人群中存在的脑梗死灶 ;二是卒中患者中存在的不能解释其症状体征的梗死灶。“无症状”并非指机体处于无病痛的良好状态。脑梗死的机制是各种原因引起的脑血管闭塞 ,导致脑组织缺血缺氧坏死 ,因此绝大多数患者都能找到缺血的征兆。所谓的“无症状”主要是指无定位体征 ,并不排除如头痛、头昏、智能减退等一般症状。同时 ,还可通过这些蛛丝马迹及早发现患者脑缺血的情况…     

Improvement in nocturnal disordered breathing after first-ever ischemic stroke: role of dysphagia

STUDY OBJECTIVE: The aim of this study was to analyze the role of dysphagia as a model of pharyngeal muscle dysfunction in the time course of nocturnal disordered breathing (NDB) in patients who experienced a first-ever ischemic stroke. DESIGN: Prospective study. PATIENTS AND INTERVENTIONS: Fifty-nine consecutive patients (mean age, 73.2 years; SD, 12.8 years) were studied. Clinical sleep and neurologic data and vascular risk factors were recorded. Two nocturnal studies using a portable autotitration device (AutoSet Portable Plus II system; ResMed; Sydney, NSW, Australia) were performed in both the acute phase (mean duration, 1.23 days; SD, 0.7 day) and the stable phase (mean duration 65.9 days; SD, 12.5 days) of the neurologic event in all patients. RESULTS: The mean total apnea-hypopnea index (AHI) measured with the autotitration device in the acute phase was 34.9 (SD, 25.2) vs 20.1 (SD, 21.7) in the stable phase, both with predominance of obstructive apnea. Patients with dysphagia (n = 30) showed the largest number of obstructive apneic episodes (OAIs) in the acute phase (AHI, 40 episodes; OAI, 30.4 episodes), with a significant reduction in this type of apnea during the stable phase of stroke (AHI, 24.7 episodes; OAI, 17.7 episodes), coinciding with the recovery of pharyngeal muscle function. In contrast, nondysphagic patients (n = 29) showed no significant changes in NDB from the acute to the stable phase of stroke. Logistic regression analysis found dysphagia to be the best independent predictor of AHI reduction of > 50% from baseline (odds ratio, 13.4; 95% confidence interval, 3.3 to 39.6; p = 0.001). CONCLUSION: The present study shows significant improvement in the number obstructive apneic events occurring in the stable phase of a first-ever ischemic stroke in patients with transient pharyngeal muscle alterations secondary to the neurologic lesion.     

Significant interaction of hypertension and homocysteine on neurological severity in first-ever ischemic stroke patients

It is not known whether combination of hypertension and high homocysteine (HHcy) impacts on stroke-related neurological severity. Our aim was to determine whether there is an interaction of hypertension and HHcy on neurological severity in first-ever ischemic stroke patients. We analyzed neurological severity among 189 consecutive first-ever ischemic stroke patients with or without hypertension or HHcy. Hypertension (odds ratio [OR]: 8.086, 95% confidence interval [CI]: 3.596–18.181, P < .001) and total homocysteine (OR: 1.403, 95% CI: 1.247–1.579, P < .001) were independently associated with neurological severity. In receiver-operating characteristic analysis, total homocysteine was a significant predictor of neurological severity (area under curve: 0.794; P < .001). A multiplicative interaction of hypertension and HHcy on more severe neurological severity was revealed by binary logistic regression (OR: 13.154, 95% CI: 5.293–32.691, P < .001). Analysis further identified a more than multiplicative interaction of hypertension and HHcy on neurological severity compared with patients without each condition (OR: 50.600, 95% CI: 14.775–173.285, P < .001). Interaction effect measured on an additive scale showed that 76.4% patients with moderate/severe neurological severity were attributed to interaction of hypertension and HHcy. Significant interaction of hypertension and HHcy on neurological severity was found on multiplicative and additive scale in first-ever Chinese ischemic stroke patients.     

The role of carotid plaque vulnerability and inflammation in the pathogenesis of acute ischemic stroke

BACKGROUND: Increasing evidences show that disruption of carotid plaque followed by arterio-arterial thromboembolism is an important mechanism in the generation of ischemic stroke. Inflammatory mechanisms play a key role in transforming structurally vulnerable plaques into functionally unstable ones. The purpose of the present study is to evaluate the roles of carotid plaque vulnerability and inflammation in the pathogenesis of acute ischemic stroke. METHODS: Fifty-two patients with acute ischemic stroke affecting the anterior circulation (stroke group) and 44 with asymptomatic carotid stenosis (asymptomatic group) were investigated. Duplex ultrasonography was used to evaluate the characteristics of carotid plaque and grading the degree of carotid stenosis. Plaque echogenicity was assessed as echolucent, predominantly echolucent, predominantly echogenic, or echogenic. Plaque surface was classified as smooth, irregular, or ulcerated. All subjects had duplex-determined 50% to 99% carotid stenosis. Serum levels of matrix metalloproteinase-9 (MMP-9), tissue inhibitors of metalloproteinases (TIMP-1), soluble CD40 ligand (sCD40L) and high-sensitivity C-reactive protein (hsCRP) were measured. RESULTS: Plaques in the stroke group were echolucent or predominantly echolucent, whereas those of the asymptomatic group were predominantly echogenic or echogenic plaques (P<0.05). Irregular and ulcerated plaques were frequently found in stroke patients, while smooth plaques were frequently detected in asymptomatic patients (P<0.05). Serum levels of MMP-9, sCD40L, hsCRP were higher in stroke than in asymptomatic patients. By contrast, serum TIMP-1 levels were significantly higher in the asymptomatic than in the stroke group. CONCLUSIONS: The results suggest that inflammation plays a crucial role in carotid plaque vulnerability and, together with carotid plaque morphology, in the pathogenesis of acute ischemic stroke.     

大脑中动脉狭窄患者皮质下梗死发病机制的研究

目的 旨在研究大脑中动脉粥样硬化性狭窄患者皮质下梗死的发病机制。 方法 利用磁共振弥散加权成像,研究86例症状性大脑中动脉粥样硬化性狭窄患者皮质下梗死的形态学表现,以及与经颅多普勒超声(TCD)监测微栓子的相关性。 结果 86例大脑中动脉粥样硬化性狭窄皮质下梗死的患者,63例(73.3％)呈多发性病灶,主要累及内交界区及半卵圆中心。TCD监测到14例(29.8％)皮质下梗死患者的微栓子,其中13例为多发性病灶,多表现为半卵圆中心梗死(P<0.001)、皮质播散性小梗死(P<0.001)以及多发性脑梗死(P<0.02)。结论 动脉-动脉栓塞与血流动力学低灌注的共同作用是大脑中动脉粥样硬化性狭窄患者皮质下多发性脑梗死的发病机制。内交界区梗死、半卵圆中心梗死为不同发病机制的两种梗死类型,后者与栓塞机制关系更为密切。     

血浆脑钠肽水平与首发急性脑梗死预后的关系

目的 探讨脑钠肽(brain natriuretic peptide,BNP)对急性脑梗死患者的预后价值.方法 纳入65例首发急性脑梗死患者和32名正常对照者.病例组神经功能缺损采用中国卒中量表(Chinese Stroke Scale,CSS)评价.血浆BNP浓度采用荧光免疫定量法检测.病例组死亡和复发性卒中事件进行随访.比较事件组与非事件组血浆BNP浓度,分析血浆BNP浓度与预后不良的关系.结果 急性腩梗死患者血浆BNP浓度为(238.7±131.6)pg/ml,显著高于健康对照组的(38.7±23.8)pg/ml(P<0.01).随访期间有9例(13.8%)患者死亡,8例(12.3%)复发非致死性卒中.死亡/复发性卒中事件组患者基线血浆BNP浓度为(304.0±134.9)pg/ml,显著高于非事件组的(214.4±120.9)pg/ml(P<0.01).血浆NBP浓度与CSS评分之间存在显著相火性(r=-0.359,P<0.05).对各种危险凶素进行多变量分析表明,BNP水平(OR=3.5,95%CI 2.1～5.8;P<0.01)、高龄(OR=4.1,95%CI 1.7～9.2;P<0.01)和CSS评分(OR=2.6,95%CI 1.6-4.3;P<0.01)均为转归不良的独立预测因素.结论 血浆BNP水平升高是急性脑梗死患者近期死亡和复发的独立预测因素.     

无症状脑梗死患者同型半胱氨酸的临床研究

目的 探讨血浆同型半胱氨酸(Hcy)与无症状脑梗死(SBI)的相关性.方法 收集研究对象213例,其中SBI患者77例,非SBI患者136例,检测患者空腹12小时后静脉血空腹血糖(FBG)、总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C)以及Hcy水平等指标.结果 SBI的患病率为36.2％.年龄、高血压病史、糖尿病史、LDL-C及Hcy升高与无症状脑梗死发生存在相关性,比值比(OR)[95％可信区间(CI)]分别为1.301(1.021 ～3.676;P ＜0.05)、1.599(1.022～3.886;P＜0.01)、1.245 (1.101～2.651;P＜0.01)、1.518(1.017～2.573;P ＜0.05)、1.100(1.032～1.173;P＜0.01).结论 Hcy是SBI的独立危险因素,对≥60岁老年人群检测Hcy,可以识别SBI的高危人群.     

胚胎型大脑后动脉与急性缺血性卒中患者梗死分布和卒中严重程度的相关性

目的 探讨胚胎型大脑后动脉(Fetal-type posterior cerebral artery, FTP)与急性缺血性卒中患者梗死分布和卒中严重程度的相关性.方法 回顾性纳入急性缺血性卒中患者.根据磁共振血管造影结果分为FTP组和非FTP组,前者进一步分为完全型FTP(complete FTP, cFTP)和部分型FTP(partial FTP, pFTP).根据弥散加权成像结果将梗死部位分为大脑前动脉(anterior cerebral artery, ACA)供血区、大脑中动脉(middle cerebral artery, MCA)供血区、大脑后动脉(posterior cerebral artery, PCA)供血区及椎基底动脉(vertebrobasilar artery, VBA)供血区.根据美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale, NIHSS)评价卒中严重程度,<8分定义为轻度卒中,≥8分定义为中重度卒中.多变量logistic回归分析确定FTP与梗死分布和卒中严重程度的相关性.结果 共纳入647例急性缺血性卒中患者,201例(31.1%)存在FTP,其中cFTP 162例(25.0%),pFTP 39例(6.0%).多变量logistic回归分析显示,cFTP和pFTP是MCA供血区梗死的独立危险因素[cFTP:优势比(odds ratio, OR)24.714,95%可信区间(confidence interval, CI)10.952~45.766,P<0.001;pFTP:OR 14.526,95% CI 6.832~25.931,P<0.001]和PCA供血区梗死的独立保护因素(cFTP:OR 0.214,95% CI 0.022~0.531,P<0.001;pFTP:OR 0.326,95% CI 0.018~0.739,P<0.001),同时也是急性缺血性卒中严重程度的独立危险因素(cFTP:OR 22.138,95% CI 12.492~64.067,P<0.001;cFTP:OR 19.510,95% CI 8.956~23.514,P<0.001).结论:cFTP和pFTP是MCA供血区梗死的独立危险因素和PCA供血区梗死的独立保护因素,同时也是中重度卒中的独立危险因素.FTP与急性缺血性卒中患者的梗死分布和卒中严重程度相关.