Study of association of severity of sleep disordered breathing and functional outcome in stroke patients

ObjectiveSleep disordered breathing (SDB) is a prevalent yet underrecognized condition that may have major adverse consequences for those affected by it. We performed a prospective observational study to seek a correlation of severity of SDB with the severity of stroke and its functional outcome.MethodsPatients with history of recent-onset stroke were recruited and underwent overnight polysomnography (PSG) after the acute phase of the stroke was over; for defining hypopneas, 3% and 4% desaturation limits were used, and the apnea−hypopnea index was respectively calculated as AHI_3% and AHI_4%. Stroke severity was graded using the Scandinavian Stroke Scale. Functional disability and neurological impairment was evaluated six weeks after the PSG using the Barthel Index (<80 = functional dependence; ≥80 = functional independence) and modified Rankins Scale (>2 = poor outcome; ≤2 = good outcome).ResultsA total of 50 patients were enrolled, 30 (60%) with ischemic stroke and 20 (40%) with hemorrhagic strokes. Of the patients, 39 (78%) had an AHI_4% of >5/h, 23 (46%) had an AHI_4% of >15/h, and 9 (18%) had an AHI_4% of >30/h. Multivariate analysis showed that body mass index (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.04–1.54, p = 0.019) and Scandinavian Stroke Scale score (stroke severity) (OR = 0.86; 95% CI = 0.76–0.96, p = 0.009) were significant risk factors for predicting SDB (AHI_4% > 15) in patients of stroke. When we looked for factors predicting outcomes, only AHI_4% (OR = 1.20; 95% CI 1.01–1.43, p value 0.041) was predictive of the functional dependence (based on Barthel Index) of the patient and AHI_4% (OR = 1.14; 95% CI 1.03–1.25, p = 0.008) and body mass index (OR = 0.75; 95% CI 0.59–0.96, p = 0.024) were found to be predictive of poor outcome (based on modified Rankins Scale). We obtained similar results, regardless of the hypopnea definition used.ConclusionIn conclusion, given the high frequency of SDB in stroke patients and its correlation with poor outcome, screening for obstructive sleep apnea in all stroke and transient ischemic attack patients may be warranted.     

Brainstem infarction and sleep-disordered breathing in the BASIC sleep apnea study

BackgroundAssociation between cerebral infarction site and poststroke sleep-disordered breathing (SDB) has important implications for SDB screening and the pathophysiology of poststroke SDB. Within a large, population-based study, we assessed whether brainstem infarction location is associated with SDB presence and severity.MethodsCross-sectional study was conducted on ischemic stroke patients in the Brain Attack Surveillance in Corpus Christi (BASIC) project. Subjects underwent SDB screening (median 13 days after stroke) with a well-validated cardiopulmonary sleep apnea-testing device (n = 355). Acute infarction location was determined based on review of radiology reports and dichotomized into brainstem involvement or none. Logistic and linear regression models were used to test the associations between brainstem involvement and SDB or apnea/hypopnea index (AHI) in unadjusted and adjusted models.ResultsA total of 38 participants (11%) had acute infarction involving the brainstem. Of those without brainstem infarction, 59% had significant SDB (AHI ⩾ 10); the median AHI was 13 (interquartile range (IQR) 6, 26). Of those with brainstem infarction, 84% had SDB; median AHI was 20 (IQR 11, 38). In unadjusted analysis, brainstem involvement was associated with over three times the odds of SDB (odds ratio (OR) 3.71 (95% confidence interval (CI): 1.52, 9.13)). In a multivariable model, adjusted for demographics, body mass index (BMI), hypertension, diabetes, coronary artery disease, atrial fibrillation, prior stroke/transient ischemic attack (TIA), and stroke severity, results were similar (OR 3.76 (95% CI: 1.44, 9.81)). Brainstem infarction was also associated with AHI (continuous) in unadjusted (p = 0.004) and adjusted models (p = 0.004).ConclusionsData from this population-based stroke study show that acute infarction involving the brainstem is associated with both presence and severity of SDB.     

Reduced cortical arousability to nocturnal apneic episodes in patients with wake-up ischemic stroke

Study objectivesSleep breathing disorders (SBD) have been linked to wake-up stroke (WUS). Respiratory arousals have an important role in responding to danger during sleep, yet currently no studies have investigated respiratory arousability in WUS. In this study, we used a clinical tool to predict low respiratory arousal threshold (ArTH), and then compared respiratory arousability in patients with WUS and non-WUS.MethodsWe enrolled 119 patients with acute ischemic stroke and assigned them into WUS (n = 34) and non-WUS (n = 85) groups. All participants underwent polysomnography (PSG) during the acute phase of stroke. The respiratory ArTH predictive tool assigns one point for each of the following: apnea-hypopnea index (AHI) < 30/h, nadir oxygen saturation (SaO₂) > 82.5%, and fraction of hypopneas > 58.3%. An ArTH score ≥2 represents low respiratory ArTH.ResultsOur results reconfirmed the association between moderate-to-severe sleep apnea syndrome and WUS (OR 2.879, 95% CI 1.17–7.089, p = 0.021). Significantly fewer participants with obstructive sleep apnea (AHI ≥ 5/h) had low respiratory ArTH in the WUS group than in the non-WUS group (34.8% vs. 68.1%, respectively, p = 0.008). High respiratory ArTH was independently associated with WUS (OR 5.556, 95% CI 1.959–15.761, p = 0.001).ConclusionsThe correlation between SBD and WUS suggests that sleep apnea might induce acute physiological changes that trigger the onset of stroke. We show that reduced respiratory arousability is associated with WUS, and hypothesize that reduced cortical capability to generate respiratory arousal may have a role in triggering stroke during sleep.     

Red Cell Distribution Width as a Predictor of One-Year Prognosis and Mortality of Endovascular Therapy for Acute Anterior Circulation Ischemic Stroke

ObjectivesTo investigate if Red cell distribution width (RDW) can predict long-term prognosis in patients with acute ischemic stroke (AIS) receiving endovascular therapy (EVT).MethodsIn this study, 102 AIS patients treated with EVT were retrospectively recruited. Clinical profiles and prognoses were collected for all patients. The patients were grouped following the modified ranking scale (MRS) scoring system as given below: a group of favorable functional outcome: 0–2; and a group of unfavorable functional outcome: 3–6.ResultsIn multivariate logistic regression, RDW (odds ratio [OR] = 2.799, 95 % confidence interval [CI] = 1.425–5.489; p = 0.003) was an independent predictor of unfavorable functional outcome, and it (OR, 1.929; 95% CI, 1.075–3.458; p = 0.028) was also an independent biomarker for all-cause mortality. The best predictive RDW cut-off value was 13.05% (sensitivity: 93.1%, specificity: 60.3%, AUC: 0.806, p < 0.001).ConclusionsThe results imply that pre-RDW is a reliable predictor of one-year prognosis and mortality after EVT in acute anterior circulation stroke patients.     

Sleep apnea-plus: prevalence, risk factors, and association with cardiovascular diseases using United States population-level data

ObjectivesThe purpose of this study was to estimate the prevalence of, to identify sociodemographic risk factors for, and to examine the association of cardiovascular diseases with sleep apnea-plus (i.e., comorbid insomnia and sleep apnea) in the general United States population.MethodsA population-based multi-year cross-sectional study design was used with data from the 2005–2008 United States National Health and Nutrition Examination Surveys (NHANES) (n = 12,593).ResultsThe prevalence of insomnia among individuals with sleep apnea (n = 236/546 or 43%) was higher compared to individuals without sleep apnea (n = 3550/12,047 or 30%). Among individuals with sleep apnea, women (OR 2.19, 95% CI 1.07–4.48) and individuals with symptoms of depression (OR 3.53, 95% CI 1.49–8.35) were significantly more likely, and individuals ages 60+ years (OR 0.43, 95% CI 0.20–0.94) and individuals with morbid obesity (OR 0.27, 95% CI 0.09–0.75) were significantly less likely, to have sleep apnea-plus. After controlling for confounders, the odds of health professional-diagnosed self-reported hypertension (OR 0.64, 95% CI 0.29–1.44), diabetes (OR 1.02, 95% CI 0.33–3.11), congestive heart failure (OR 0.67, 95% CI 0.19–2.44), myocardial infarction (OR 1.80, 95% CI 0.49–6.67), and stroke (OR 0.82, 95% CI 0.18–3.77), as well as objectively measured risk factors for these conditions, were not significantly different between individuals with sleep apnea-plus and individuals with sleep apnea-alone.ConclusionsThe prevalence of insomnia in sleep apnea is high, and substantially greater than in the general population, and this has important implications for the management of sleep apnea patients. Similar to sleep apnea-alone, individuals with sleep apnea-plus have elevated rates of cardiovascular diseases compared to the general population. Given the elevated rates of cardiovascular diseases among individuals with sleep apnea-plus, along with their known poor CPAP compliance, identification of individuals with sleep apnea-plus and treatment of their concomitant insomnia is important.     

Women with symptoms of sleep-disordered breathing are less likely to be diagnosed and treated for sleep apnea than men

BackgroundWomen are often underrepresented at sleep clinics evaluating sleep-disordered breathing (SDB). The aim of the present study was to analyze gender differences in sleep apnea diagnosis and treatment in men and women with similar symptoms of SDB.MethodsRespiratory Health in Northern Europe (RHINE) provided information about snoring, excessive daytime sleepiness (EDS), BMI and somatic diseases at baseline (1999–2001) and follow-up (2010–2012) from 4962 men and 5892 women. At follow-up participants were asked whether they had a diagnosis of and/or treatment for sleep apnea.ResultsAmong those with symptoms of SDB (snoring and EDS), more men than women had been given the diagnosis of sleep apnea (25% vs. 14%, p < 0.001), any treatment (17% vs. 11%, p = 0.05) and CPAP (6% vs. 3%, p = 0.04) at follow-up.Predictors of receiving treatment were age, BMI, SDB symptoms at baseline and weight gain, while female gender was related to a lower probability of receiving treatment (adj. OR 0.3, 95% CI 0.3–0.5).In both genders, the symptoms of SDB increased the risk of developing hypertension (adj OR, 95% CI: 1.5, 1.2–1.8) and diabetes (1.5, 1.05–2.3), independent of age, BMI, smoking and weight gain.ConclusionsSnoring females with daytime sleepiness may be under-diagnosed and under-treated for sleep apnea compared with males, despite running a similar risk of developing hypertension and diabetes.     

The effect of sleep apnea on all-cause mortality in nondialyzed chronic kidney disease patients

BackgroundThe prevalence of sleep-disordered breathing (SDB) in people with chronic kidney disease (CKD) is high. Studies on the effects of sleep apnea (SA) on treatment outcomes have been mostly focused on dialyzed CKD or renal transplant patients. Studies on the effects of SA on all-cause mortality in nondialyzed CKD patients are scarce.MethodsWe enrolled and followed up all adults who were referred for diagnostic testing for sleep apnea between March 2007 and July 2014, had undergone polysomnography, and whose records of serum creatinine levels were available. The outcomes were all-cause mortality and renal outcome.ResultsA total of 1454 participants were included in the study. Of these, 103 patients (7.08%) had CKD and 38 patients (2.61%) died. CKD was associated with central sleep apnea (CSA) (odds ratio [OR] = 5.158 [95% confidence interval {CI} = 1.992–13.355], p = 0.001) and severe SDB (OR = 1.737 [1.119–2.695], p = 0.014). CSA was a risk factor for all-cause mortality in nondialyzed subjects (adjusted hazard ratio [HR]= <4.250 [CI = 1.560–11.573], p = 0.005), whereas CSA was found to be a stronger risk factor for all-cause mortality in subjects with CKD (adjusted HR = 40.728 [CI = 4.765–348.117], p = 0.001). Mixed sleep apnea was related to rapid decline of renal function in nondialyzed subjects (adjusted HR = 1.932 [CI = 1.183–3.155], p = 0.009), whereas, OSA was (adjusted HR = 3.315 [CI = 1.188–9.248], p = 0.022) in CKD subjects.ConclusionIn nondialyzed patients, CKD was each associated with central sleep apnea (CSA) and severe SDB. CSA was an independent risk factor for all-cause mortality, and was a more evident mortality risk in CKD patients than in non-CKD participants. Rapid decline of renal function may play a role in the mortality of CKD patients associated with SA.     

Association of sleep apnea with clinically silent microvascular brain tissue changes in acute cerebral ischemia

The aim of this study was to determine the importance of sleep apnea in relation to clinically silent microvascular brain tissue changes in patients with acute cerebral ischemia. Patients with acute cerebral ischemia prospectively underwent nocturnal respiratory polygraphy within 5 days from symptom-onset. Sleep apnea was defined as apnea–hypopnea-index (AHI) ≥5/h. Experienced readers blinded to clinical and sleep-related data reviewed brain computed tomography and magnetic resonance imaging scans for leukoaraiosis and chronic lacunar infarctions. Ischemic lesions were considered clinically silent when patients did not recall associated stroke-like symptoms. Functional outcome was assessed with modified Rankin Scale at discharge, 6 and 12 months. Fifty-one of 56 (91 %) patients had sleep apnea of any degree. Patients with moderate-to-severe leukoaraiosis (Wahlund score ≥5) were found to have higher mean AHI than those with none or mild leukoaraiosis (34.4 vs. 12.8/h, p < 0.001). Moderate-to-severe sleep apnea (AHI ≥15/h) was found to be an independent predictor of moderate-to-severe leukoaraiosis (adjusted OR 6.03, 95 % CI 1.76–20.6, p = 0.0042) and of moderate-to-severe leukoaraiosis associated with clinically silent chronic lacunar infarctions (adjusted OR 10.5, 95 % CI 2.19–50.6, p = 0.003). The higher the Wahlund score and the AHI, the more likely unfavorable functional outcome resulted over time (p = 0.0373). In acute cerebral ischemia, sleep apnea is associated with clinically silent microvascular brain tissue changes and may negatively influence functional outcome. Routine sleep apnea screening and further investigation of possible long-term effects of non-invasive ventilatory treatment of sleep apnea appear warranted in this at-risk population.     

Prevalence and Determinants of Sleep Apnea in Patients with Stroke: A Meta-Analysis

ObjectivesRecent meta-analyses have noted that ∼70% of transient ischemic attack (TIA)/stroke patients have sleep apnea. However, the heterogeneity between studies was high and did not appear to be accounted by the phase of stroke. We conducted an updated meta-analysis and aimed to determine whether the prevalence of sleep apnea amongst stroke patients differs by the subtype, etiology, severity and location of stroke and hence could account for some of the unexplained heterogeneity observed in previous studies.Materials and MethodsWe searched Medline, Embase, CINAHL and Cochrane Library (from their commencements to July 2020) for studies which reported the prevalence of sleep apnea by using polysomnography in TIA/stroke patients. We used random-effects model to calculate the pooled prevalence of sleep apnea and explored whether the prevalence differed by stroke characteristics.ResultsSeventy-five studies describing 8670 stroke patients were included in this meta-analysis. The overall prevalence of sleep apnea was numerically higher in patients with hemorrhagic vs. ischemic stroke [82.7% (64.4–92.7%) vs. 67.5% (63.2–71.5%), p=0.098], supratentorial vs. infratentorial stroke [64.4% (56.7–71.4%) vs. 56.5% (42.2–60.0%), p=0.171], and cardioembolic [74.3% (59.6–85.0%)] vs. other ischemic stroke subtypes [large artery atherosclerosis: 68.3% (52.5–80.7%), small vessel occlusion: 56.1% (38.2–72.6%), others/undetermined: 47.9% (31.6–64.6%), p=0.089]. The heterogeneity in sleep apnea prevalence was partially accounted by the subtype (1.9%), phase (5.0%) and location of stroke (14.0%) among reported studies.ConclusionsThe prevalence of sleep apnea in the stroke population appears to differ by the subtype, location, etiology and phase of stroke.     

Thrombolytic therapy in ischemic stroke patients with pre-stroke depression in the telestroke vs non-telestroke

Background and PurposeThrombolysis therapy remains the gold standard in acute ischemic stroke treatment, and rates of treatment with rtPA in ischemic stroke patients with comorbid depression has yet to be fully investigated. This study aims to examine clinical risk factors associated with inclusion or exclusion for rtPA in acute ischemic stroke populations with pre-stroke depression in the telestroke versus a non-telestroke setting.MethodsWe collected retrospective data from a regional stroke registry for pre-stroke depressed ischemic stroke patients from January 2010 to June 2016. Logistic regression was used to determine demographic and baseline clinical risk factors associated with inclusion and exclusion from rtPA.Results. In the adjusted analysis, increasing age (OR = 1.064, 95% CI, 1.006-1.125, P = 0.029), improved ambulation (OR = 3.513, 95% CI, (0.855–14.436, P = 0.018) and sleep apnea (OR = 4.458, 95% CI, 0.731–27.182, P = 0.05) were associated with inclusion for rtPA, while Caucasian race (OR = 0.119, 95% CI, 0.0168–0.908, P = 0.040), systolic blood pressure (OR = 0.945, 95% CI, 0.906–0.985, P = 0.008), and direct admission (OR = 0.028, 95% CI, 0.003–0.317, P = 0.004) were associated with exclusion from rtPA. In the telestroke setting, INR (OR = 1.016, 95% CI, 0–5.393, P = 0.163) was not significantly associated with rtPA inclusion or exclusion.ConclusionIdentifying contraindicators associated with exclusion from rtPA is significant to improve the use thrombolytic therapy in the telestroke and non telestroke settings.     

Effect of Sleep-Disordered Breathing During Rapid Eye Movement Sleep and Non-Rapid Eye Movement sleep on Acute Ischemic Stroke

ObjectivesSleep-disordered breathing adversely impacts stroke outcomes. We investigated whether sleep-disordered breathing during rapid eye movement sleep and non-rapid eye movement sleep differentially influenced stroke outcomes.Materials and MethodsAcute ischemic stroke patients who finished polysomnography within 14 days of stroke onset from April 2010 to August 2018 were reviewed. Patients were divided into four groups according to apnea-hypopnea index during rapid eye movement sleep and non-rapid eye movement sleep. The modified Rankin Scale was used to evaluate short-term outcome. During January and April 2019, another follow-up was performed for long-term outcomes, including stroke-specific quality-of-life scale, modified Rankin Scale, stroke recurrence and death.ResultsOf 140 patients reviewed, 109 were finally recruited. Although patients with sleep-disordered breathing during non-rapid eye movement sleep only and with sleep-disordered breathing during both rapid eye movement sleep and non-rapid eye movement sleep had higher apnea-hypopnea indices and more disrupted sleep structures, short-term and long-term outcomes did not significantly different between four groups. In Logistic regression analysis, apnea-hypopnea index (p = 0.013, OR 1.023, 95%CI 1.005–1.042) was found independently associated with short-term outcome. Rapid eye movement sleep latency (p = 0.045, OR 0.994, 95%CI 0.987–1.000) was found independently associated with quality of life. Apnea-hypopnea indices during rapid eye movement sleep or non-rapid eye movement sleep were not significantly associated with short-term or long-term outcomes.ConclusionsApnea-hypopnea index is an independent risk factor of short-term outcome of acute ischemic stroke while sleep-disordered breathing during rapid eye movement sleep and non-rapid eye movement sleep do not affect stroke outcomes differently.     

Racial and ethnic differences in sleep-disordered breathing and sleep duration among stroke patients

ObjectiveWe sought to characterize racial and ethnic differences in pre- and post-stroke sleep-disordered breathing (SDB) and pre-stroke sleep duration.MethodsWithin the Brain Attack Surveillance in Corpus Christi cohort of patients with ischemic stroke (8/26/2010-1/31/2020), pre-stroke SDB risk was assessed retrospectively using the Berlin Questionnaire. Post-stroke SDB was defined by prospective collection of the respiratory event index (REI) using the ApneaLink Plus performed shortly after stroke. Pre-stroke sleep duration was self-reported. We used separate regression models to evaluate the association between race/ethnicity and each outcome (pre-stroke SDB, post-stroke SDB, and pre-stroke sleep duration), without and with adjustment for potential confounders.ResultsThere was no difference in pre-stroke risk of SDB between Black and non-Hispanic white (NHW) participants (odds ratio (OR) 1.07, 95% CI 0.77-1.49), whereas MA (Mexican American), compared to NHW, participants had a higher risk of SDB before adjusting for demographic and clinical variables (OR 1.26, 95% CI 1.08-1.47). Post-stroke SDB risk was higher in MA (estimate 1.16, 95% CI 1.06-1.28) but lower in Black (estimate 0.79, 95% CI 0.65-0.96) compared to NHW participants; although, only the ethnic difference remained after adjustment. MA and Black participants had shorter sleep duration than NHW participants (OR 0.83, 95% CI 0.72-0.96 for MA; OR 0.67, 95% CI 0.49-0.91 for Black participants) before but not after adjustment.ConclusionsRacial/ethnic differences appear likely to exist in pre- and post-stroke SDB and pre-stroke sleep duration. Such differences might contribute to racial/ethnic disparities in stroke incidence and outcomes.     

Prevalence and vascular risk factors of basal ganglia calcifications in patients at risk for cerebrovascular disease

Background and purposeRisk factors for and meaning of basal ganglia calcifications outside Fahr syndrome are poorly understood. We aimed to assess the prevalence of basal ganglia calcifications and the association with vascular risk factors.Materials and methods1133 patients suspected of acute ischemic stroke from the Dutch acute stroke (DUST) study who underwent thin-slice unenhanced brain CT were analyzed. Basal ganglia calcifications were scored bilaterally as absent, mild (dot), moderate (multiple dots or single artery) and severe (confluent). Uni- and multivariable logistic regression analysis was used to determine possible risk factors (age, gender, history of stroke, smoking, hypertension, diabetes mellitus, hyperlipidemia, body mass index (BMI), renal function and family history of cardiovascular disease under 60 years) for presence of basal ganglia calcifications and ordinal regression analysis for severity of basal ganglia calcifications.ResultsMean age was 67.4 years (SD: 13.8), 56.8% were male. 337 (29.7%) patients had basal ganglia calcifications, of which 196 (58%) were mild, 103 (31%) moderate, 38 (11%) severe. In multivariable logistic regression analysis, age (OR: 1.02, 95% CI 1.01–1.03, P < 0.01) and BMI (OR: 0.95, 95% CI 0.91–0.98, p 0.01) were significantly associated with the presence of basal ganglia calcifications. Ordinal regression analysis gave comparable results. Age (OR: 1.02, 95% CI 1.01–1.03, P < 0.01) and BMI (OR: 0.95, 95% CI 0.92–0.99, P 0.01) were significantly associated with severity of basal ganglia calcifications.ConclusionsIn this study with patients suspected of acute ischemic stroke, basal ganglia calcifications were common and significantly associated with older age and lower BMI.     

Sleep-disordered breathing: Impact on functional outcome of ischemic stroke patients

Background and purposeSleep-disordered breathing (SDB) is more prevalent in stroke patients than age- and sex-matched controls, but the relationship between SDB and functional outcome of stroke patients is unclear. The aim of our study was to determine the prevalence of SDB in ischemic stroke and its influence on functional outcome at 3 and 6 months after stroke onset.MethodsIn a prospective study, 60 patients were selected by polysomnography (PSG). The apnea–hypopnea index (AHI) was determined 6.5 ± 3.2 days after stroke onset. Neurologic severity at admission was assessed by the Scandinavian Stroke Scale (SSS) and outcome by the Barthel Index (BI). Patients were evaluated on admission, 3 and 6 months after stroke onset.ResultsAmong the 60 patients, 39 (65%) patients had SDB (AHI ? 5); of these, 30 patients (50%) had AHI ? 15 and 18 (30%) > 30. On Logistic regression analysis, the BI at 3 months was independently predicted by SSS (OR = 0.74, 95% CI [0.62–0.88], P = 0.001) and AHI (OR = 1.09, 95% CI [1.02–1.17], P < 0.05). At 6 months, the BI was predicted only by SSS (OR = 0.83, 95% CI [0.74–0.92], P = 0.001).ConclusionsSDB is common in patients during acute phase after stroke onset. SDB appears to be associated with a worse functional outcome during the early recovery period following stroke, increasing the likelihood of dependency.     

Care-needs Certification in the National Long-Term Care Insurance is Useful for Assessment of Premorbid Function in Older Japanese Patients with Stroke

ObjectiveTo investigate the effects of premorbid long-term care insurance (LTCI) care-need certification on functional improvement during acute hospitalization in older patients with stroke.MethodsIn this single-center prospective cohort study, we assessed LTCI care-needs certification and the modified Rankin Scale (mRS) at the premorbid stage, on admission, and at hospital discharge in older patients with stroke. We also assessed adverse events during hospitalization. The main outcome was the presence of functional improvement during hospitalization (mRS on admission < mRS at discharge). Multivariate analysis was performed to investigate the relationship between functional improvement and premorbid LTCI care-need certification.ResultsIn total, 246 older patients with stroke were enrolled in this study. There was a significant independent association between premorbid LTCI care-needs certification (care level 1 = odds ratio [OR]: 0.26, 95% CI: 0.10–0.72, p = 0.01; Care level 2 = OR: 0.27, 95% CI: 0.10–0.73, p = 0.01; care level 3–5 = OR: 0.21, 95% CI: 0.08–0.56, p = 0.002; Not applicable = reference) and functional improvement.ConclusionsPremorbid LTCI care-need certification is associated with short-term functional improvement in older patients with stroke. Assessment of premorbid LTCI care-needs certification is valid for predicting functional improvement in older patients with stroke.     

Outcomes of Thai patients with acute ischemic stroke after intravenous thrombolysis

The purpose of this study was to assess outcomes in Thai patients after treatment with intravenous recombinant tissue plasminogen activator (rtPA) and to determine the factors associated with good outcome and death.MethodsPatients with acute ischemic stroke who were treated with intravenous rtPA at Thammasat University Hospital between June 2007 and April 2010 were included. The measured outcome variables were good outcome (mRS 0,1) and death at 3 months. Stepwise multivariable analyses were performed by including the prespecified factors that were associated with the measured outcome variables in the univariate analysis.ResultsThe sample size was 197 patients. At 3 months, 93 patients (47%) had good outcomes while 23 patients (12%) died within the same period. Severe stroke (OR 0.19, 95% CI 0.08–0.44, p-value < 0.0001) and history of hypertension (OR 0.39, 95% CI 0.16–0.93, p-value = 0.033) were independently related to bad outcome at 3 months, while receiving intravenous nicardipine (OR 2.76, 95% CI 1.09–6.94, p-value = 0.032) was associated with good outcome. Severe stroke (OR 5.89, 95% CI 1.29–26.85, p-value = 0.022) and pretreatment high blood glucose levels (OR 8.06, 95% CI 1.21–53.62, p-value = 0.031) each were independently associated with patient death.ConclusionsStandard-dose intravenous rtPA in a cohort of Thai patients led to better clinical outcomes and comparable death rates when compared to other Asian cohorts receiving intravenous rtPA. Several factors were independently associated with patient outcomes at 3 months.     

Polysomnography findings in pediatric spinal muscular atrophy types 1–3

BackgroundSleep disordered breathing (SDB) causes sleep disturbance and daytime symptoms in children with neuromuscular disorders. Although polysomnography (PSG) findings are well described in many neuromuscular disorders, there are limited reports from children with spinal muscular atrophy (SMA). The aim of this study was to determine the sleep architecture and breathing characteristics and non-invasive ventilation (NIV) use in our pediatric SMA cohort.MethodsWe conducted a cross-sectional cohort study of all children with SMA in Queensland, Australia. Children were Nusinersen naïve and had a full diagnostic PSG in 2018. The PSG was scored and reported by a single pediatric sleep physician in accordance with American Academy of Sleep Medicine Criteria (2012).ResultsIn sum, 31 children (18 males), Six with Type 1, 16 with Type 2 and nine with Type 3, aged 0.25–18.8 years old were studied. SDB was seen in each SMA type and was more pronounced during rapid eye movement (REM) sleep. Type 1: all patients exhibited SDB, three (50%) with central sleep apnea (CSA) and three (50%) with mixed disease. Type 2: five (31%) had CSA, one (6%) mixed disease, seven (44%) had early SDB and three (19%) had normal sleep breathing. Type 3: four (44%) children had CSA and five had early SDB. No child exhibited obstructive sleep apnea (OSA) alone.Starting NIV significantly reduced mean total PSG Apnea-Hypopnea Index (AHI) scores from a grouped mean of 15.4 events per hour (SD ± 14.6; 95% CI 6.1–24.7) to 4.0 events per hour (SD ± 4.2, 95% CI 1.2–6.5, p = 0.01).ConclusionSDB is common in children with SMA and was present in all types. CSA was the most common disorder; with mixed SDB also present in type 1 and 2 SMA.     

Wake-up stroke is not associated with obstructive sleep apnea

Objective/BackgroundObstructive sleep apnea is a risk factor for stroke. This study sought to assess the relationship between obstructive sleep apnea (OSA) and wake-up strokes (WUS), that is, stroke symptoms that are first noted upon awakening from sleep.Patients/methodsIn this analysis, 837 Brain Attack Surveillance in Corpus Christi (BASIC) project participants completed an interview to ascertain stroke onset during sleep (WUS) versus wakefulness (non-wake-up stroke, non-WUS). A subset of 316 participants underwent a home sleep apnea test (HSAT) shortly after ischemic stroke to assess for OSA. Regression models were used to test the association between OSA and WUS, stratified by sex.ResultsOf 837 participants who completed the interview, 251 (30%) reported WUS. Among participants who underwent an HSAT, there was no significant difference in OSA severity [respiratory event index (REI)] among participants with WUS [median REI 17, interquartile range (IQR) 10, 29] versus non-WUS (median REI 18, IQR 9, 30; p = 0.73). OSA severity was not associated with increased odds of WUS among men [unadjusted odds ratio (OR) 1.011, 95% confidence interval (95% CI) 0.995, 1.027] or women (unadjusted OR 0.987, 95% CI 0.959, 1.015). These results remained unchanged after adjustment for age, congestive heart failure, body mass index, and pre-stroke depression in men (adjusted OR 1.011, 95% CI 0.994, 1.028) and women (adjusted OR 0.988, 95% CI 0.959, 1.018).ConclusionsAlthough OSA is a risk factor for stroke, the onset of stroke during sleep is not associated with OSA in this large, population-based stroke cohort.     

Leukoaraiosis on Magnetic Resonance Imaging Is Related to Long-Term Poor Functional Outcome after Thrombolysis in Acute Ischemic Stroke

Objective

Leukoaraiosis (LA) has been suggested to be related to the poor outcome or the occurrence of symptomatic intracerebral hemorrhage (sICH) after acute ischemic stroke. We retrospectively investigated the influences of LA on long-term outcome and the occurrence of sICH after thrombolysis in acute ischemic stroke (AIS).

Methods

In this study, we recruited 164 patients with AIS and magnetic resonance image (MRI)-detected thrombolysis. The presence and extent of LA were assessed using the Fazekas grading system. The National Institutes of Health Stroke Scale score was used to assess the baseline measure of neurologic severity, and the modified Rankin Scale score assessment was used up to 1 year after thrombolysis.

Results

Of 164 subjects, 56 (34.2%) showed LA on MRI. Compared to the 108 patients without LA, the patients with LA were of much older age (p<0.01), had a higher prevalence of hypertension (p<0.01), and had a much poorer outcome at 90 days (p=0.05) and 1 yr (p=0.01) after thrombolysis. There were no significant differences in sICH between patients with and without LA on MRI. In univariate analysis for the occurrence of poor outcome at 90 days after thrombolysis, the size of ischemic lesion on diffusion weighted images (DWI), [odds ratio (OR), 1.03; 95% confidence interval (95% CI), 1.01-1.04; p<0.01], recanalization (OR, 0.03; 95% CI, 0.01-0.10; p<0.01), sICH (OR, 12.2; 95% CI, 1.54-95.8), neurologic severity (OR, 1.17; 95% CI, 1.09-1.25; p<0.01), blood glucose level (OR, 1.01; 95% CI, 1.00-1.02; p=0.03), and the presence of LA on MRI (OR, 2.01; 95% CI, 1.04-3.01; p=0.04) were statistically significant. In multivariate analysis, neurologic severity (OR, 1.14; 95% CI, 1.04-1.24; p<0.01), recanalization (OR, 0.03; 95% CI, 0.01-0.11; p<0.01), lesion size on DWI (OR, 1.02; 95% CI, 1.01-1.03; p=0.02), serum glucose level (OR, 1.01; 95% CI; 1.01-1.02; p=0.03), and the presence of LA on MRI (OR, 3.2; 95% CI, 1.22-8.48; p<0.01) showed statistically significant differences. These trends persisted up to 1 yr after thrombolysis.

Conclusion

In this study, we demonstrated that the presence of LA on MRI might be related to poor outcome after use of intravenous tissue plasminogen activator in AIS.     

Prevalence of sleep apnea at the acute phase of ischemic stroke with or without thrombolysis

ObjectiveThe aim of the study was to compare the prevalence, type, and severity of sleep apnea during the acute phase of ischemic stroke among patients either receiving or not receiving thrombolysis.MethodsWe recruited 246 consecutive adult ischemic stroke patients. Patients underwent cardiorespiratory sleep study with portable three-channel device during the first 48 h after the symptom onset of ischemic stroke.ResultsWe enrolled 110 (65.5% male) stroke patients in the thrombolysis group and 94 (59.6% male) in the nonthrombolysis group. In the thrombolysis group, the median National Institutes of Health Stroke Scale (NIHSS) score was higher (5.5) compared to the nonthrombolysis group (2.0) (p < 0.001). There was a lower incidence of lacunar (17.3% vs 36.2%, p = 0.002) and cerebellar (2.7% vs 16.0%, p < 0.001) strokes and a higher frequency of middle cerebral artery syndrome (60.9% vs 33.0%, p < 0.001) in the thrombolysis group compared to the nonthrombolysis group. Sleep apnea defined as an apnea–hypopnea index (AHI) ≥ 5/h was diagnosed in 186 (91.2%) patients, its prevalence being higher in the thrombolysis (96.4%) compared to the nonthrombolysis (85.1%) group (p = 0.007). The mean baseline AHI was 33.7/h in the thrombolysis group compared to 26.8/h in the nonthrombolysis group (p = 0.017).ConclusionSleep apnea was present in the vast majority of ischemic stroke patients. The stroke patients treated with thrombolysis were more likely to have sleep apnea, to have elevated NIHSS score at admission, and to be younger. Sleep apnea was more severe among those receiving thrombolysis as compared to those who were not.Clinical trial registrationURL: http://www.clinicaltrials.cov. Unique identifier: NCT01861275.