Predictors of dependence after MCA ischemic stroke submitted to thrombolysis

Objectives: Stroke is one of the most common causes of disability-adjusted life years worldwide. The aim of this study is to identify variables associated with dependence at 3 months and also after the first 3 months after the first-ever ischemic stroke (IS) in middle cerebral artery (MCA) territory submitted to intravenous thrombolysis (IVT).

Methods: A single-center cohort study of patients with first-ever MCA IS treated with IVT at the Hospital de Clínicas, Universidade Federal do Paraná, was followed over 5 years. Logistic regression was performed to determine predictors of early and late dependence.

Results: A total of 144 patients were included; 48.6% women, and 47.2% were dependent at 3 months after stroke. NIHSS at admission (OR = 1.3, 95%CI = 1.16–1.45, p < 0.001), large artery atherosclerosis (LAA) stroke (OR = 4.11, 95%CI = 1.31–12.85, p = 0.014) and pneumonia during hospitalization (OR = 9.17, 95%CI = 1.42–59.07, p = 0.019) were predictors for early dependence. For the late dependence analyses, 99 patients were included; 49.5% women and 39.4% were dependent after 3 months of stroke. NIHSS at admission (OR = 1.33, 95%CI = 1.15–1.54, p < 0.001), pneumonia during hospitalization (OR = 11.08, 95%CI = 1.45–84.73, p = 0.019) and seizure after discharge (OR = 5.82, 95%CI = 1.06–32.01, p = 0.040) were predictors for late dependence.

Discussion: .Dependence is an important indicator of the efficacy of stroke care. Besides it was not possible to evaluate rehabilitation, this is the first study on predictors of post-stroke dependence that focus exclusively on patients with first-ever MCA IS submitted to IVT. NIHSS, LAA stroke, in-hospital pneumonia and seizures after discharge were associated with dependence after first-ever MCA IS submitted to IVT.     

Fasting Hyperglycemia and Long-term Outcome in Patients with Acute Ischemic Stroke Treated with Mechanical Thrombectomy

BackgroundLittle is known about the prognostic role of fasting glucose after mechanical thrombectomy (MT).AimsWe investigated whether fasting glucose on the next day after MT was associated with long-term outcome in acute ischemic stroke patients according to diabetes.MethodsWe retrospectively analyzed 181 consecutive patients with acute anterior circulation ischemic stroke who underwent MT in 2 comprehensive stroke centers in Poland. Glucose levels were evaluated on admission and on the next day after MT. Fasting hyperglycemia (FHG) was defined as the glucose level above 5.5 mmol/L. Unfavorable outcome was defined as modified Rankin scale (mRS) of 3-6 at day 90 from stroke onset.ResultsPatients with FHG had higher mRS at 3-month follow-up compared with those without FHG (3.71 ± 2.56 versus 1.87 ± 2.22, P < .001). In the subgroup analyses, FHG was associated with poor neurological outcome in the group without diabetes (3.74 ± 2.52 versus 1.81 ± 3.74, P < .001) but not with diabetes (3.64 ± 2.67 versus 2.30 ± 3.74, P= .11). Patients without diabetes who had FHG were older, had higher glucose on admission, higher prevalence of atrial fibrillation, cardioembolic stroke etiology and bleeding brain complications compared with the group with normal fasting glucose. After adjustment for potential confounders, fasting glucose (odds ratio [OR] 1.46; 95% CI 1.19-1.79, P < .001), age (OR 1.06; 95% CI 1.02-1.10, P = .001), successful reperfusion (OR 0.09; 95% CI 0.04-0.22, P < .001) and baseline NIHSS score (OR 1.18; 95% CI 1.08-1.29, P < .001) were predictors of mRS 3-6 at 3-month follow-up in the whole group. In the subgroup without diabetes, fasting glucose (OR 1.57; 95% CI 1.17-2.11, P = .002), age (OR 1.05; 95% CI 1.01-1.08, P = .008), successful reperfusion (OR 0.11; 95% CI 0.04-0.30, P < .001) and baseline NIHSS score (OR 1.14; 95% CI 1.04-1.26, P = .011) were independent predictors of unfavorable 3-month outcome.ConclusionsFasting glucose on the next day after MT in patients with acute ischemic stroke is an independent risk factor for worse 3-month outcome.     

A simple clinical and MRI scale to predict good outcome in t-PA patients

Abstract

Background and purpose: The frequency of good outcome at 3 months after tissue plasminogen activator (t-PA) therapy is ～35%. The present study aimed to devise a simple scale to predict good outcome using clinical factors and magnetic resonance imaging (MRI) findings before and immediately after t-PA infusion.

Methods: Consecutive patients with acute ischemic stroke treated with t-PA within 3 hours of stroke onset were studied prospectively. We assessed clinical factors independently associated with good outcome [modified Rankin scale (mRS): 0-1] at 3 months after t-PA therapy. We created a simple scale to predict good outcome in t-PA patients using factors selected by multivariate logistic regression analysis.

Results: Subjects comprised 105 patients (69 men; median age, 74 years). Multivariate logistic regression analysis revealed the following independent factors associated with good outcome: baseline National Institutes of Health Stroke Scale (NIHSS) <11 [odds ratio (OR), 13·64; 95% confidence interval (CI), 3·588-51·822; P = 0·0001], glucose <150 mg/dl (OR, 3·76; 95%CI, 1·014-13·963; P = 0·0475), and early recanalization within 1 hour after t-PA infusion (OR, 5·28; 95%CI, 1·179-23·656; P = 0·0296). Those three variables were selected for use in the good outcome scale, with NIHSS <11 as 2 points, glucose <150 mg/dl as 1 point, and early recanalization as 1 point. Frequencies of patients with good outcome for each score were as follows: score 0, 0·0%; score 1, 7·1%; score 2, 43·5%; score 3, 65·4%; and score 4, 71·4%. The C statistic for the score was 0·849 (95%CI, 0·776-0·922).

Conclusion: A simple clinical and MRI scale can predict good outcome in t-PA patients.     

Mean platelet volume/platelet count ratio as a predictor of 90-day outcome in large artery atherosclerosis stroke patients

Objective: Previous studies reported a lower platelet count (PC) level and a higher mean platelet volume (MPV) level in severe ischemic stroke. We define MPV/PC as the platelet ratio (PR). This study investigates the relationship between PR and 90-day outcome of large artery atherosclerosis (LAA) stroke.

Materials and Methods: A retrospective analysis was conducted on 338 LAA patients in two hospitals by looking up the electronic medical record (EMR). The 90-day functional outcome was divided into good and poor according to the modified Rankin Scale (mRS) score.

Results: Multivariate logistic regression analysis of the First Affiliated Hospital of Wenzhou Medical University (Hospital 1) revealed that PR (OR1.083, 95%CI [1.044, 1.123], P < 0.001) and National Institutes of Health Stroke Scale (NIHSS) score were independent predictors of the poor outcome. Analysis from the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University (Hospital 2) showed that PR (OR1.071, 95%CI [1.039, 1.104], P < 0.001), NIHSS score and age were independent adverse prognostic predictors. Furthermore, higher quartiles of PR presented an incremental OR value compared to the first quartile PR in multivariate regression. In Hospital 1, the cut-off value of PR to predict 90-day outcome was 39.23 (sensitivity: 74.24%, specificity: 55.17%, area under the curve (AUC): 0.694, P < 0.001). In Hospital 2, the optimal cut-off value of PR was 46.08 (sensitivity: 61.40%, specificity: 73.74%, AUC: 0.695, P < 0.001).

Conclusions: Platelet ratio on admission is an independent predictor for 90-day outcome in LAA stroke patients and it has a good predictive effect.     

Factors related to unfavorable outcome in minor ischemic stroke

BackgroundStroke recurrence and disability are important challenges to overcome in patients with minor ischemic stroke. The aim of our study was to determine the factors associated with unfavorable outcomes in patients with minor ischemic stroke.MethodsThis was a prospective cohort study including patients with minor ischemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score ≤ 4 who were treated at the Bach Mai Hospital stroke center from June 15, 2021, to September 15, 2022. Unfavorable outcome was defined as mRS 2-6 at 90 days. Multivariable logistic regression analysis was conducted to assess risk factors related to clinical outcomes.ResultsOf 678 patients presenting with minor ischemic stroke, there were 90 (13.3%, 90/678) patients with no intracranial artery imaging. Hence, 588 were patients analyzed, of whom 6.0% received thrombolytic therapy, 8.5% developed NIHSS > 4 in 24 hours, and 30.4% had intracranial stenosis > 50%. Compared with the group of unfavorable outcomes, the favorable outcome group had more NIHSS 0-1 (29.9% vs.8.7%, P<0.001), lower cardioembolic (3.2% vs.7.9%, P=0.021), low IV-tPA ratio (4.8% vs.10.3%, P=0.019), lower NIHSS progression > 4 in the first 24 hours (3.9% vs.25.4%, P<0.001), and lower ICAS rate (28.1% vs.38.9%, P=0.02). Multivariable regression analysis of factors affecting unfavorable outcomes included baseline NIHSS 2-4 (OR, 3.85; 95% CI, 1.97-7.52), NIHSS progression > 4 (OR, 7.57; 95% CI, 3.80-15.10), and ICAS (OR 1.68; 95%CI, 1.07-2.64).ConclusionsIn patients with minor ischemic stroke, unfavorable outcomes were associated with baseline NIHSS 2-4, NIHSS progression > 4 points in 24 hours, and ICAS. These factors may identify a patient population in need of close monitoring and at higher risk of adverse outcomes.     

Prognosis of Subtypes of Acute Large Artery Atherosclerotic Cerebral Infarction by Evaluation of Established Collateral Circulation

Background: The prognosis of acute ischemic stroke is related to collateral circulation, which is different with different pathogenesis. Objective: To explore the prognosis of acute large atherosclerotic (LAA) cerebral infarction with different pathogenesis by assessing the establishment of collateral circulation. Methods: 108 patients with acute LAA cerebral infarction in our hospital, who failed to thrombolytic or thrombectomy in the acute phase were selected and classified by Chinese ischemic stroke subclassification (CISS). They were evaluated by National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS). CT angiography (CTA) of head and neck were used to evaluate the collateral circulation for patients with large vessel stenosis or occlusion within one week of admission. The CTA collateral scores (CS) were recorded in a dichotomized fashion (ie, poor vs good). Results: Patients with good CS had significantly lower NIHSS score and good prognosis at 2 weeks and 3 months than patients with poor CS (P < 0.001). The arterial-to-arterial embolization mechanism was the highest in the ratio of good CS and good prognosis at 3 months (P < 0.001). Multivariate Logistic regression analysis showed that baseline NIHSS score (OR=1.407, 95%CI:1.153–1.717, P=0.001) was an independent factor affecting poor CS. The NIHSS score at baseline (OR=0.604, 95%CI:0.436–0.837, P=0.002) and good CS (OR=39.552, 95%CI:8.908–175.618, P=0.000) were important predictors of good prognosis at 3 months. Conclusion: The prognosis and collateral circulation of acute LAA cerebral infarction with different pathogenesis was different. Baseline NIHSS score and collateral circulation had great impact on prognosis at 3 months.     

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.     

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.     

脑白质高信号与孤立大脑中动脉重度狭窄或闭塞患者临床预后的相关性研究

目的 探讨脑白质高信号（white matter hyperintensity,WMH）与孤立大脑中动脉（middle cerebral artery,MCA）重度狭窄或闭塞患者临床预后的关系。方法 前瞻性连续纳入就诊于新乡医学院第一附属医院神经内科,发病在72 h内的孤立MCA M1段重度狭窄或闭塞的急性缺血性卒中患者。收集患者的临床资料,入院时采用NIHSS评估卒中严重程度,采用Fazekas评估WMH严重程度。本研究的主要结局为发病90 d和1年时的神经功能结局,根据mRS将患者分为预后良好（mRS 0～2分）和预后不良（mRS>2分）组,单因素分析比较2组的基线指标、WMH等脑小血管病影像学指标、侧支循环评级等因素;采用多因素分析判断预后不良的独立危险因素。本研究的次要结局包括卒中进展、发病90 d和1年卒中复发,采用单因素logistic回归分析评估WMH与发病3 d内卒中进展、随访90 d和1年卒中复发的关系。结果 最终纳入117例患者,男性74例（63.2%）,平均60.6±9.9岁。90 d随访时,60例患者预后良好,57例患者预后不良,多因素logistic回归分析显示Fazekas总分（OR 1.612,95%CI 1.245～2.087,P<0.001）、入院时NIHSS（OR 1.215,95%CI 1.025～1.440,P=0.025）、侧支循环不良（OR 3.111,95%CI 1.188～8.142,P=0.021）是预后不良的独立危险因素;1年随访时,86例患者预后良好,31例患者预后不良,多因素logistic回归分析显示Fazekas总分（OR 1.495,95%CI 1.083～2.065,P=0.014）、入院时NIHSS（OR 1.725,95%CI 1.359～2.193,P<0.001）、侧支循环不良（OR 4.217,95%CI 1.218～14.598,P=0.023）与预后不良独立相关。单因素logistic回归分析显示WMH与卒中进展及复发无相关性。结论 WMH与MCA重度狭窄或闭塞患者临床预后密切相关,高Fazekas总分、入院时NIHSS评分高、侧支循环不良可作为评定MCA重度狭窄或闭塞患者临床预后的独立危险因素。     

Post-stroke depression: different characteristics based on follow-up stage and gender–a cohort perspective study from Mainland China

Background: Post-stroke depression (PSD) is a common and important comorbidity in patients after stroke. It negatively impacts stroke survivors’ outcomes. Plenty of studies have investigated risk factors for PSD, especially sex differences. However, the results remain inconsistent. In this study, we explored the prevalence and risk factors for PSD both in the acute phase and the chronic phase of stroke, emphasizing on the impact of gender in PSD.

Methods: About 1094 patients with first-ever ischemic stroke were included in the study. Patients were followed up, respectively, 2 weeks, 3 months, and 12 months after stroke. Data collected included demographic and stroke-related factors, and whether patients still suffer from PSD at each time points. T-test, chi-square test, and Wilcoxon rank-sum test were used to explore the group differences between patients with PSD and without PSD, and between female and male patients. Logistic regression was performed to investigate the risk factors for PSD both in the acute and the chronic stage of stroke.

Results: The prevalence of PSD was 25.4, 17.6, and 12.4%, respectively 2 weeks, 3 months, and 12 months after stroke. Female patients had higher prevalence of PSD compared with male patients (31.4 vs. 22.4% 2 weeks after stroke; 20.05 vs. 16.22% 3 months after stroke; 15.04 vs. 11.05% 12 months after stroke). In the acute stage of stroke, female gender (OR 1.686 95%CI 1.155–2.462) and National Institutes of Health Stroke Scale (NIHSS) score (OR 1.118 95%CI 1.076–1.162) were independent risk factors for PSD. However, in the chronic stage of stroke, risk factors for PSD were different. At 3 months, NIHSS score (OR 1.082 95%CI 1.037–1.128), smoking (OR 1.772 95%CI 1.163–2.701), and frontal lobe lesion (OR 2.331 95%CI 1.472–3.692) were independent risk factors for PSD. On the other hand, education level (OR 0.693 95%CI 0.486–0.998) was a protective factor. About 12 months after stroke onset, NIHSS score (OR 1.113 95%CI 1.062–1.167) and living alone (OR 3.608 95%CI 1.538–8.466) were risk factors for PSD.

Conclusion: PSD is common in stroke survivors, and female patients have higher prevalence of PSD. Risk factors for PSD in the acute phase are different from that in the chronic phase of stroke. Female gender is an independent risk factor for PSD in the acute stage of stroke. Smoking, frontal lobe lesion, and living alone are predictive factors for PSD in the chronic stage of stroke. NIHSS score is a risk factor for PSD both in the acute and in the chronic stage of stroke. Further studies are needed to understand the mechanisms underlying the elevated prevalence of PSD in female.     

Prognostic value of plasma HMGB1 in ischemic stroke patients with cerebral ischemia-reperfusion injury after intravenous thrombolysis

BackgroundTo investigate the value of plasma high mobility group box protein 1 (HMGB1) in evaluating the prognosis of cerebral ischemia-reperfusion injury (CIRI) in ischemic stroke patients.Methods132 ischemic stroke patients were recruited. Before and after thrombolytic therapy at 2 h, 6 h, 12 h, 24 h, and 36 h, the Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) were recorded. The Modified Rankin scale (mRS) was used to assess the prognosis at 3 months.ResultsThe NIHSS score, GCS score and plasma HMGB1 level peaked at 6 h after thrombolytic therapy, and plasma HMGB1 level was positively correlated with infarct volume and NIHSS score, and negatively correlated with GCS score. Plasma HMGB1 level at 6 h had the highest value in identifying patients with poor unfavorable functional outcome after 3 months, with a sensitivity of 86.8% and a specificity of 74.0%. Logistic regression results showed that plasma HMGB1 had a strong association with unfavorable functional outcome [odds ratio (OR) =1.621, P<0.001]. After adjusting for infarct volume and NIHSS score did not attenuate the association (OR=1.381, P=0.005). Finally, we found that plasma HMGB1 at 6 h had the highest value in identifying patients with non-survival after 3 months (χ²=28.655, P<0.001). Logistic regression results showed that plasma HMGB1 had a strong association with non-survival (OR=2.315, P<0.001). After adjusting for infarct volume and NIHSS score did not attenuate the association (OR=2.013, P<0.001).ConclusionPlasma HMGB1 exerts a good predictive value for CIRI in ischemic stroke patients, and its increased expression is correlated with worse prognosis.     

Number of Stent Retriever Passes Associated with Clinical Outcome After Mechanical Thrombectomy in Acute Ischemic Stroke

ObjectiveTo evaluate the association between the number of stent retriever (SR) passes and clinical outcome after mechanical thrombectomy (MT) in patients with acute ischemic stroke(AIS).MethodsWe retrospectively analyze data collected from consecutive patients with large vessel occlusion (LVO) in anterior circulation treated with MT. Baseline characteristics, number of SR passes, symptomatic intracranial hemorrhage (sICH), clinical outcome measured by modified Rankin Scale (mRS) at 90 days after MT were collected. Multivariate logistic regression analysis was performed to assess the association between number of SR passes and patients’ clinical outcome.Results134 patients with LVO achieved successful reperfusion (mTICI 2B/3) were enrolled. Univariate analysis showed that patients with favorable outcomes were less likely to need more than three passes of SR (9.8%vs39.7%, p = 0.001). In a multivariable analysis, baseline NIHSS score (OR 0.922, 95%CI 0.859∼0.990, p = 0.025), more than three passes of SR (OR 0.284, 95%CI0.091∼0.882, p = 0.030) and symptomatic intracranial hemorrhage (OR 0.116,95%CI0.021∼0.650, p = 0.014) each independently predicted poor outcome after MT at 90 days.ConclusionThe need for more than three passes of SR may be used as an independent predictor of poor outcome after MT in patients with acute ischemic stroke at 90 days.     

Early Cognitive Assessment Following Acute Stroke: Feasibility and Comparison between Mini-Mental State Examination and Montreal Cognitive Assessment

Objectives: Cognitive assessment is not performed routinely in the acute stroke setting. We investigated factors associated with cognitive impairment and the differences between the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores in patients with acute stroke. Methods: In this prospective study, 881 consecutive patients (median age, 73 years) with acute stroke were enrolled. Clinical characteristics, such as education, vascular risk factors, premorbid cognitive status using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), and stroke severity, were assessed. Cognitive performance was measured using MMSE and MoCA within 5 days of stroke onset. Results: Both MMSE and MoCA were feasible in 621 (70.5%) patients. Factors independently associated with nonfeasibility were age (odds ratio [OR]: 1.05; 95% confidence interval [CI]: 1.02-1.08), IQCODE score (OR: 1.02; 95%CI: 1.00-1.04), and National Institutes of Health Stroke Scale (NIHSS) score (OR, 1.16; 95%CI, 1.12-1.20). Impaired MoCA (with a cut-off <26/30) performance was observed in 544 of 621 (87.6%) patients. Factors independently associated with cognitive impairment were age (OR: 1.06; 95%CI: 1.03-1.10) and NIHSS score (OR: 1.34; 95%CI: 1.14-1.57). Eighty percent of patients with normal MMSE scores had an impaired MoCA score (MMSE-MoCA mismatch). The differences were highest in the visuospatial (94.8% versus 65.3%; P < .0001), recall (76.6% versus 35.6%; P < .0001), abstraction (82.5% versus 49.8%; P < .0001), and language (72.3% versus 65.9%; P < .0001) domains between the normal MMSE and MoCA group and MMSE-MoCA mismatch group. Conclusions: The MoCA can be particularly useful in patients with cognitive deficits undetectable on the MMSE in the acute stroke phase.     

Acute Ischemic Stroke Outcome and Preceding Anticoagulation: Direct Oral Anticoagulants Versus Vitamin K Antagonists

Background and Purpose: Acute ischemic stroke (AIS) severity and clinical course are less known in direct oral anticoagulants (DOAC) users. We aimed to explore the outcome of AIS in patients pretreated with vitamin-K-antagonists (VKA) and DOAC. Methods: A retrospective study was performed. Patients pretreated with oral anticoagulants (OAC) for nonvalvular atrial fibrillation admitted for AIS in a stroke unit between 2016-01-01 and 2018-08-31 were included. The primary endpoint was mortality during the hospital stay, and secondary endpoints were neurologic improvement at stroke unit discharge and good functional outcome 90 days after AIS. Results: A total of 156 patients were included (83 on VKA and 73 on DOAC). Stroke severity (defined by NIHSS on admission) was comparable in both groups (AVK 13.0 [4.0-20.0] versus DOAC 11.0 [4.0-17.0], P = .435). Infratherapeutic levels and/or inappropriate low dose of OAC was also similar between groups (P = .152) and was not associated with stroke severity (P = .631) or mortality (P = .788). VKA (OR 12.616, P = .035, 95%CI 1.19-133.64) and PH2 hemorrhagic transformation (OR 7.516, P = .024, 95%CI 1.31-43.20) were associated with higher mortality in multivariate analysis. Higher stroke severity (OR .101, P < .001, 95%CI .037-.279) and VKA usage (OR .212, P = .003, 95%CI .08-.58) were associated with worse functional outcome at 3 months. Reperfusion therapy was significantly associated with neurologic improvement during stroke unit stay (OR 3.969, P = .009, 95%CI 1.42-11.11) but not with the functional outcome (P = .063). Conclusions: Nonvalvular atrial fibrillation patients pretreated with DOAC admitted for AIS had a better outcome when compared to VKA, although stroke severity was similar between groups.     

Depressive symptoms and 10-year risk for cardiovascular morbidity and mortality

Abstract

Objectives. Depression is associated with increased physical morbidity and overall mortality. As less is known about how much depression increases the 10-year risk for fatal and nonfatal cardiovascular (CV) events, we evaluated the cross-sectional risk with two well-characterized risk functions measuring CV mortality and total CV event risk. Methods. The prevalence of increased depressive symptoms was measured with the Beck Depression Inventory (BDI), and the SCORE and Framingham risk functions were calculated in a middle-aged population-based sample (N=923). For metabolic syndrome (MetS), the modified National Cholesterol Education Program – Adult Treatment Panel III criteria were employed. Results. Depressive symptoms were associated with increased CV mortality and morbidity risk in men: OR for SCORE 2.9; 95%CI 1.4–5.7 and OR for Framingham function 2.2 (95%CI 1.1–4.2). In women, the corresponding figures were 1.4 (95%CI 0.3–6.9) and 1.3 (95%CI 0.7–2.6). The BDI scores showed significant correlations with SCORE (r=0.18 for men, P < 0.001; and r=0.14 for women, P=0.002), and Framingham function (for men r=0.16, P < 0.001; and for women r=0.13, P=0.005). Conclusions. Our results suggest that screening and effective treatment of depression are important in the primary and secondary prevention of cardiovascular events, especially in males.     

Relation between lipoprotein-associated phospholipase A<Subscript>2</Subscript> mass and incident ischemic stroke severity

Background

Manifestations of ischemic stroke vary widely, and serum biomarkers may be useful for stratification of risk of severe stroke. This study evaluated the association of lipoprotein-associated phospholipase A₂ (Lp-PLA₂) mass and initial severity.

Methods

We employed a retrospective analysis on our hospital-based registry and recruited 488 first-onset ischemic stroke patients admitted within 24 h after onset and with Lp-PLA₂ mass measured. Stroke severities evaluated by National Institutes of Health Stroke Scale (NIHSS) were compared between Lp-PLA₂ categories dichotomized by median. Multivariate logistic regression was used to detect the independent risk factors of severe stroke (NIHSS ≥?7) and receiver operator curve (ROC) was constructed to detect the value of addition of Lp-PLA₂ to the model of other risk factors for predicting severe stroke.

Results

Of the overall patients, the median admission NIHSS scores was 3 and 28.1% had severe manifestation. Admission NIHSS scores were different between patients of Lp-PLA₂ above and under the median (median NIHSS 4 vs. 3, P?<?0.001). Lp-PLA₂ levels was correlated with admission NIHSS (r?=?0.268, P?<?0.001). Logistic regression showed Lp-PLA₂ category (OR 2.37, 95%CI 1.44–3.90, P?<?0.001) and levels per 100 ng/ml (OR 1.69, 95%CI 1.35–2.11, P?<?0.001) were both independently associated with severe stroke. Addition of Lp-PLA₂ category and levels to other independent risk factors both increased the area under curves (from 0.676 to 0.718 with category and 0.734 with levels).

Conclusion

Lp-PLA2 was independently related to admission severity in ischemic stroke patients, implying a potential predictive value of Lp-PLA2 for severe stroke in prevention.

     

Factors associated with delay to carotid endarterectomy for acute ischaemic stroke in South Australia: A multicentre retrospective cohort study

BackgroundThe greatest benefits of carotid endarterectomy (CEA) accrue when performed within two weeks of acute ischaemic stroke (AIS) due to symptomatic carotid stenosis. Previous studies have identified multiple factors contributing to CEA delay.AimsTo determine factors associated with delayed CEA in patients admitted to tertiary stroke centres within a major metropolitan region with AISMethodsIn a retrospective cohort study, consecutive patients admitted to the tertiary hospitals with stroke units within South Australia (Lyell McEwin Hospital, Royal Adelaide Hospital and Flinders Medical Centre) between 2016 to 2020 were included. Univariable and multivariable logistic regression were used to identify individual factors associated with time from symptom onset to CEA of over two weeks.ResultsA total of 174 patients were included. The median time to CEA was 5 days (IQR 3-9.75). Delayed CEA beyond 14 days occurred in 28/174 (16%). Factors most associated with delayed CEA included presentation to a tertiary hospital without onsite Vascular Surgical Unit (OR 3.71, 95%CI 1.31-10.58), history of previous stroke (OR 3.38, 95% CI 1.11-9.84) and presenting NIHSS above 6 (OR 5.16, 95% CI 1.60-16.39).ConclusionThis study identified that presentation to a tertiary hospital without a Vascular Surgery Unit, history of previous stroke and presenting NIHSS above 6 were associated with delay to CEA in AIS patients in South Australia. Interventional studies aiming to improve the proportion of patients that receive CEA within 14 days are required.     

Combined clopidogrel–aspirin treatment for high risk TIA or minor stroke does not increase cerebral microbleeds

Abstract

Objectives:

To study whether Clopidogrel–Aspirin combined treatment for high risk transient ischaemic attack (TIA) or minor stroke results in increased number of lesions associated with anti-thrombotic cerebral haemorrhage or cerebral micro-bleeds (CMB) than aspirin alone treatment.

Methods:

The patients recruited in CHANCE test in our hospital participated in this study. We made a comparison between treatments Aspirin–Clopidogrel combined group and the Aspirin alone group in the numbers of CMB and subsequent cerebral haemorrhages. In addition, we analysed the association between the increased numbers of CMB and subsequent intracerebral haemorrhages. All 129 patients with high risk TIA with microbleeds or minor stroke within 24?hours after the onset (average age 65.9?±?9.3, 48.7% were male patients) were divided randomly into two groups: (1) 67 patients were given combination therapy with clopidogrel and aspirin (clopidogrel at an initial dose of 300?mg, then 75?mg per day for 90?days, plus aspirin at a dose of 75?mg per day for the first 21?days);(2) the rest patients were given aspirin treatment (75?mg per day for 90?days). All participants received open-label aspirin at a clinician-determined dose of 75–300?mg on the first day.

Results:

The CMB were found in 52.7% of all patients in both groups. There was no siginificant difference between the Aspirin group and the Aspirin–clopidogrel treated group, though the latter showed some slight increase in CMB (Odds ratios (OR)?=?1.16, 95% confidence intervals (CI) =?0.54–2.47, P?=?0.71). But the numbers of CMB were remarkably associated with the number of primary existing CMB (OR?=?6.46, 95%CI 2.57–16.23, P?<?0.001), especially that of primary existing CMB ≥?3.In addition, the increasing numbers of CMB associated with primary CMB lesions, which located in corticosubcortical area (CSC) (OR?=?4.69, 95%CI 1.51–14.53, P?=?0.007).

Conclusions:

For the treatment of high-risk TIA or minor stroke patients, the clopidogrel–aspirin treatment did not increase the number of CMB than Aspirin alone. It appears that the extent of CMB was associated with the extent of existing CMB occurred in previous stroke, which was mostly located in cortical, subcortical zone.     

Blood group and ischemic stroke,myocardial infarction,and peripheral vascular disease: A meta-analysis of over 145,000 cases and 2,000,000 controls

ObjectiveCardiovascular illnesses have been associated to ABO blood types, specifically through an effect on von Willebrand factor and factor FVIII levels. We conducted a meta-analysis to comprehensively explore the relationship between blood groups and ischemic stroke, myocardial infarction, and peripheral vascular disease.Materials and methodsA comprehensive meta-analysis was undertaken to investigate blood groups and ischemic stroke (IS), myocardial infarction (MI) and peripheral vascular disease (PVD). Odds ratios (OR) were used to assess the relationship between blood groups and disease. RevMan v5,4 was used to statistically analyse the results. Risk of bias was assessed using the Newcastle-Ottawa scale.ResultsA total of 72 studies (18 ischemic stroke, 37 myocardial infarction, 17 peripheral vascular disease) met our search criteria, totalling 145,499 cases and 2,113,736 controls. Mean age ranged between 18 and 90 years. Compared to blood group-O, non-O blood group had an increased association with IS (OR=1.13, 95%Cl: 1.07-1.21, P < 0.001), MI (OR=1.17, 95%Cl: 1.11-1.24, P < 0.001) and PVD (OR=1.15, 95%Cl: 1.04-1.28, P=0.005). Compared to blood group-O, blood group A had a stronger statistically significant association to IS (OR=1.19, P=0.001), MI (OR=1.22, P < 0.001) and PVD (OR=1.15, P=0.03). Blood group-B has the lowest risk associated with MI (OR=1.09, P=0.01). In addition, blood groups AB had a stronger statistically significant association to IS (OR=1.24, P=0.01), and MI (OR=1.20, P < 0.001) compared with the other blood groups.ConclusionsCompared to blood group-O, groups A and AB are strongly associated to ischemic stroke, myocardial infarction, and peripheral vascular disease.     

急性缺血性脑卒中动脉通畅性恶化的相关因素及预后

目的探讨急性缺血性脑卒中(AIS)动脉通畅性恶化(APD)的相关因素及预后。方法收集778例AIS患者的临床资料。根据是否发生APD将患者分为APD组及非APD组。于入院时和入院24 h对患者进行头颅MRI检查。采用NIHSS评分评价入院24 h神经功能,记录入院48 h的早期缺血性卒中复发率;于3个月和12个月采用mRS评分评估预后;记录第7 d、3个月、12个月的死亡率。结果与非APD组比较,APD组年龄、3个月mRS评分及高血压病史、入院前使用降压药、入院前使用降脂药、脑白质疏松的比率显著降低,入院及24 h NIHSS评分、12个月mRS评分及意识水平下降、颅内动脉狭窄、颅外动脉狭窄和侧支循环状态良好的比率显著升高(均P<0.05)。两组间TOAST分型的其他明确病因型卒中(SOE)及不明病因型卒中(SUE)差异有统计学意义(P=0.000,P=0.028)。Logistic回归分析显示,高血压病史(OR=0.46,95%CI:0.30～0.85,P=0.002)、入院NIHSS评分(OR=1.06,95%CI:1.03～1.11,P<0.001)、颅内动脉狭窄(O...