Effect of smoking status on outcome after acute ischemic stroke

BACKGROUND: The status of smoking as a risk factor for the occurrence of stroke is well established. However, there is a paucity of data on the relationship between smoking status and acute stroke outcomes. We evaluated the role of recent smoking as a prognostic factor following acute ischemic stroke. METHODS: We analyzed data from patients enrolled in the Intravenous Magnesium Efficacy in Stroke (IMAGES) trial. Outcome measures studied included change in IMAGES stroke score, poor functional outcomes at day 30 and 90 (defined as Rankin Scale >1 and Barthel Index <95), and survival over the first 3 months after stroke. The independent effect of smoking status (subjects who had smoked in the past year) on outcome was evaluated by logistic regression analysis and Cox's proportional hazards model, adjusting for variables known to predict outcome after ischemic stroke. RESULTS: There were 2,386 subjects in the IMAGES efficacy dataset, including 615 recent or current smokers and 1,771 nonsmokers, among whom smokers were younger (p < 0.0001). After adjusting for covariates, smokers had increased odds of poor 90-day functional outcome independently of other statistically significant predictor variables, as assessed by Rankin Scale (odds ratio 1.38; 95% confidence interval 1.09-1.75) and Barthel Index (odds ratio 1.42; 95% confidence interval 1.13-1.79) at day 90. Smoking status did not affect survival at day 90. CONCLUSIONS: Current or recent smokers experience poorer functional outcomes than nonsmokers 3 months after acute ischemic stroke.     

Bilateral carotid artery occlusion with transient or moderately disabling ischaemic stroke: clinical features and long-term outcome

Information on the prognosis of patients with transient ischaemic attack or moderately disabling ischaemic stroke associated with bilateral internal carotid artery (ICA) occlusion is scarce. We prospectively studied 57 consecutive patients (46 men; mean age 60 ± 9 years) with bilateral ICA occlusion who had presented with unilateral transient or moderately disabling cerebral or retinal ischaemic symptoms. We determined the long-term risk of recurrent ischaemic stroke and the composite outcome of stroke, myocardial infarction or vascular death. Four patients had a recurrent ischaemic stroke during a mean follow-up of 5.9 years, resulting in an annual stroke rate of 1.2% (95% confidence interval (CI) 0.3–3.1). Risk factors for recurrent ischaemic stroke could not be identified. Eighteen patients suffered a stroke, myocardial infarction or vascular death, resulting in an annual rate for major vascular events of 5.3% (95% CI 3.1–8.3). Age and a history of ischaemic heart disease were significant risk factors for future vascular events. Patients with transient or moderately disabling symptoms of cerebral or retinal ischaemia associated with bilateral ICA occlusion have a relatively low risk of recurrent ischaemic stroke. Although this study was not designed to compare conservative treatment with surgical intervention, the favourable outcome suggests that a policy of medical therapy and control of risk factors may be justified in these patients.     

Cerebral artery calcification in patients with acute cerebrovascular diseases: determinants and long-term clinical outcome

Background and purpose: Coronary artery calcium is an independent predictor of all‐cause mortality. We sought to examine the determinants of intracranial cerebral artery calcification (CAC) and its association with long‐term outcome in a large prospective cohort of stroke patients. Methods: Consecutive patients hospitalized because of acute stroke (ischaemic and intracerebral hemorrhage) or TIA throughout a large medical center were systematically assessed and followed up for 1 year. Intracranial CAC was assessed from baseline brain CT blinded to clinical data. Patients were categorized to no, mild, and severe CAC according to their total CAC score. Determinants of CAC were studied with logistic regression analysis. Risk of death, Barthel Index ≤ 60 or death and living in a nursing facility or death were assessed. Results: Amongst 1049 patients (mean age: 70 ± 13 years, 59% males) CAC was present in 727 (69%) patients. The main determinants of CAC were increasing age (OR 1.4, 95% CI 1.3–1.6, per 5 years), diabetes (OR: 2.1, 1.4–3.0), smoking (1.4, 1.0–2.2), hypertension (1.4, 1.0–2.1), and prior coronary heart disease (1.9, 1.3–2.9). CAC was associated with mortality and poor outcome amongst patients with ischaemic stroke; however, after adjusting for age and stroke severity, no significant association was observed. In patients with intracerebral hemorrhage, outcomes were not related to CAC. Conclusions: Intracranial CAC is highly prevalent in patients with acute stroke and its main determinants are older age, diabetes, smoking, hypertension, and prior coronary heart disease. Associations between CAC and mortality or poor functional outcome in the first year after ischaemic stroke are mainly age‐ and stroke severity‐driven.     

Specific DWI lesion patterns predict prognosis after acute ischaemic stroke within the MCA territory

BACKGROUND: Apart from diffusion-weighted imaging (DWI) lesion volume and diffusion-perfusion mismatching, there is limited information about neuroradiological predictors of early prognosis after an ischaemic stroke. This study sought to identify specific DWI lesion patterns that would help prediction of early prognosis of three different endpoints: unstable hospital course, recurrence of stroke, and poor neurological outcome at 90 days after ischaemic stroke. METHODS: A total of 426 patients with acute cerebral infarcts within the middle cerebral artery territory were prospectively studied. Using the DWI data the patients were divided into six groups (territorial, other cortical, small superficial, internal border zone, small deep, and other deep infarcts), and any recurrent strokes and prognosis over the following 90 days were recorded. RESULTS: DWI lesion pattern was a stronger and more consistent independent outcome predictor than DWI lesion volume. The specific DWI lesion patterns associated with each endpoint differed. An unstable hospital course was frequently observed in patients with internal border zone infarcts, whereas recurrent strokes after the index stroke were commoner in those who had small superficial infarcts (p<0.05 in both cases). Similarly, poor outcome after stroke was associated with older age, severe neurological deficits at admission, and a DWI lesion pattern showing internal border zone infarcts. CONCLUSIONS: The results of the present study indicate that the DWI lesion pattern may help in recognition of the likely differences in the early prognostic endpoints after ischaemic stroke, and DWI analysis may guide targeted interventions to prevent negative outcomes.     

High prevalence of unrecognized cerebral infarcts in first-ever stroke patients with cardioembolic sources

Background:  With magnetic resonance imaging (MRI) analysis, we investigated the prevalence, clinical significance, and factors related to the presence of unrecognized cerebral infarcts in patients with first-ever ischaemic stroke.
Methods:  We consecutively included patients who were admitted with first-ever stroke. Unrecognized cerebral infarct was defined as an ischaemic infarction or primary intracerebral hemorrhage on MRI irrelevant to the index stroke, without acute lesions on diffusion-weighted image.
Results:  Of the total 203 patients, 78 (39.4%) patients were observed as having unrecognized cerebral infarct. Patients with high-risk cardioembolic sources (e.g., atrial fibrillation) more frequently had unrecognized stroke than those without ( P  = 0.008, 21/36 [58.3%] vs. 57/167 [34.1%]). On univariate analysis, male sex ( P  = 0.027) and cardioembolic source ( P  = 0.008) were associated with the presence of unrecognized cerebral infarcts. After adjustment for gender, age and risk factors, the presence of cardioembolic sources independently increased the risk of unrecognized cerebral infarct ( P  = 0.002, odds ratio 3.56, 95% confidence interval 1.58–8.02). Regarding clinical outcome at 3 months, the presence of unrecognized cerebral infarct was not associated with the poor clinical outcome.
Conclusion:  In our study, the presence of cardioembolic sources was an independent risk factor for the unrecognized cerebral infarct in patients with first-ever stroke.     

Plasma homocysteine is a risk factor for recurrent vascular events in young patients with an ischaemic stroke or TIA

Objectives Young patients with an ischaemic stroke or transient ischaemic attack (TIA) often have no vascular risk factors. Hyperhomocysteinaemia is an established risk factor for stroke in elderly patients but it is uncertain whether it is also important for the prognosis of young ischaemic stroke and TIA patients. We examined the possible effect of the plasma homocysteine level on the risk of recurrent vascular events in patients between 18 and 45 years of age. Methods The study population consisted of 161 consecutive patients with a recent cerebral infarction or TIA. Data on the primary event and the homocysteine level were collected retrospectively from hospital records. General practitioners and patients were contacted by telephone to record vascular events and the type of medication used during the follow–up period. Vascular events included cerebral infarction, TIA, pulmonary embolism, venous thrombosis, myocardial infarction and peripheral arterial disease. Results A Kaplan- Meier curve showed a dose effect relationship between event-free survival time and tertiles of the homocysteine level (Log rank statistic 5.91; p = 0.05). The Cox hazard ratio, after adjustment for homocysteine lowering treatment, was 1.7 (95 % CI, 1.1 to 2.8) for any vascular outcome event, 1.9 (95% CI, 1.1 to 3.0) for arterial outcome events and 1.8 (95 % CI, 1.1 to 2.9) for cerebral outcome events. Conclusions In spite of our small number of outcome events we found a significant association at the 95% confidence level between homocysteine level and the risk of recurrent vascular events in young patients with an ischaemic stroke or TIA. The association is of the same magnitude as in elderly people.     

The smoking-thrombolysis paradox and acute ischemic stroke

Smokers with acute myocardial infarction have better outcomes after thrombolysis than nonsmokers. The authors evaluated the independent effect of smoking on short-term outcome following IV thrombolysis for acute ischemic stroke. After adjusting for covariates, recent smokers who received thrombolysis had a significantly greater drop in 24-hour median stroke severity scores from baseline than nonsmokers who received thrombolysis and lower mortality over 1 year.     

Dense middle cerebral artery sign: an indicator of poor outcome in middle cerebral artery area infarction.

Thirteen patients with a dense appearance of the horizontal part of the middle cerebral artery (MCA) "dense middle cerebral artery sign" in CT scans taken within 24 hours after onset of ischaemic stroke had considerably poorer prognosis than controls with stroke, but without the sign. A hyperdense appearance of the MCA is known to be associated with thromboembolism, but dense middle cerebral artery sign is also an early warning of a large infarction, brain oedema and poor prognosis in infarction in the MCA area.     

Cerebrospinal fluid enolase in stroke.

This study relates the level of alpha and gamma enolase in cerebrospinal fluid sampled within 4 days of a stroke to the volume of the cerebral infarct measured on the CT image and to the clinical outcome of the patient. Twenty-eight patients were studied, two with transient ischaemic attacks and 26 with completed stroke due to infarction. The cerebrospinal fluid enolase was raised in the two patients with transient ischaemic attacks and 23 with completed stroke. There was a positive correlation between the volume of the infarct and the level of cerebrospinal fluid alpha and gamma enolase. A high cerebrospinal fluid enolase was always associated with a poor prognosis.     

Associations of cigarette smoking with intracranial atherosclerosis in the patients with acute ischemic stroke

Background

Although cigarette smoking has been established as an important risk factor for stroke, the effect on the atherosclerotic stenosis, which are based on observational studies, have been controversial. We set out to examine the differences in the risk factors between smokers and nonsmokers and to investigate the association of cigarette smoking with cerebral arterial stenosis.

Methods

A total of 989 consecutive patients with acute noncardioembolic ischemic stroke were prospectively enrolled from June 2004 to January 2010. The risk factor profiles were compared between smokers and nonsmokers. We analyzed the degree of stenosis in all MRA, and evaluated influencing factors in the patients with intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) who were randomly matched by age and sex.

Results

There were differences in the distribution of risk factors between the 467 (70.0%) nonsmokers and the 215 (30.0%) smokers. Nonsmokers were older (71.7 ± 11.0 versus 61.7 ± 12.0, p < 0.001) and had a higher frequency of hypertension than smokers had (75.4% versus 64.0%, p = 0.002). When smokers and nonsmokers were age- and sex-matched, smoking was more prevalent in patients with ICAS than with ECAS (32.9% versus 28.2%). Conditional regression analysis revealed that smoking and hypertension increased the odds of ICAS [smoking, odds ratio (OR): 1.83, p = 0.026; hypertension, OR: 1.84, p = 0.01], whereas hyperlipidemia increased the odds of ECAS (OR: 1.87, p = 0.034).

Conclusion

The distributions of the major risk factors for ischemic stroke were different between smokers and nonsmokers. Cigarette smoking may be more associated with ICAS than with ECAS after adjusting for potential risk factors.     

The Prognostic Factors That Influence Long-Term Survival in Acute Large Cerebral Infarction

Objective

We retrospectively evaluated the prognostic factors that can influence long-term survival in patients who suffered acute large cerebral infarction.

Methods

Between June 2003 and October 2008, a total of 178 patients were diagnosed with a large cerebral infarction, and, among them, 122 patients were alive one month after the onset of stroke. We investigated the multiple factors that might have influenced the life expectancies of these 122 patients.

Results

The mean age of the patients was 70±13.4 years and the mean survival was 41.7±2.8 months. The mean survival of the poor functional outcome group (mRS≥4) was 33.9±3.3 months, whereas that of the good functional outcome group (mRS≤3) was 58.6±2.6 months (p value =0.000). The mean survival of the older patients (≥70 years) was 29.7±3.4 months, whereas that of the younger patients (<70 years) was much better as 58.9±3.2 months (p value=0.000). Involvement of ACA or PCA territory in MCA infarction is also a poor prognostic factor (p value=0.021). But, other factors that are also known as significant predictors of poor survival (male gender, hypertension, heart failure, atrial fibrillation, diabetes mellitus, a previous history of stroke, smoking, and dyslipidemia) did not significantly influence the mean survival time in the current study.

Conclusion

Age (older versus younger than 70 years old) and functional outcome at one month could be critical prognostic factors for survival after acute large cerebral infarction. Involvement of ACA or PCA territory is also an important poor prognostic factor in patients with MCA territorial infarction.     

Occult lung cancer manifesting within the first year after stroke

BackgroundLung cancer and stroke share smoking as a major cause of disease. We investigated prevalence and risk of occult lung cancer with manifestation during the first year after stroke.MethodsAll patients >40 years of age with incident stroke in Denmark 2003–2015 were identified through the Danish Stroke Registry (n=85,893) and matched 1:10 on age and sex to the Danish background population without a history of stroke (n=858,740). Linking data to the Danish Cancer Registry we determined prevalence of occult primary lung cancer defined as the event of previously unknown lung cancer during a one-year follow-up in the stroke and the background population. Cox regression models with adjustments for demographics, co-morbidities and stroke risk factors were used to study risk compared to the background population.ResultsPrevalence (per 1000 person-years) of occult lung cancer in the stroke cohort was 5.3; in the background cohort 2.6. Prevalence separately for current smokers (n=26,055) was 9.6; ex-smokers (n=20,035) 6.5; never-smokers (n=27,268) 1.4. Risk of occult lung cancer (adjusted) was increased HR 1.95 in the stroke population. In the stroke population adjusting for stroke risk factors age (HR 1.24 per 10 years) and smoking (HR 7.1 in current smokers; HR 1.6 in ex-smokers) were the only significant risk factors for occult lung cancer.ConclusionsOccult lung cancer is rarely found in stroke patients who have never smoked. It is not uncommon in smokers in whom 1% of current smokers had occult lung cancer that became manifest within the first year after stroke.     

脑梗死发生时间对动脉瘤性蛛网膜下腔出血患者临床结局的影响

目的探究脑梗死发生时间对动脉瘤性蛛网膜下腔出血患者(aSAH)临床结局的影响。方法纳入2010年3月至2016年6月来我院进行就诊的aSAH患者395例,其中发生早期脑梗死患者74例,迟发性脑梗死患者77例,两者并发患者29例。分析aSAH术后脑梗死患者临床特征;采用多因素Logistic回归分析术后脑梗死发生的独立危险因素和长期预后的独立危险因素。结果多因素Logistic回归分析显示Hunt～Hess≥Ⅲ级和手术夹闭术是早期脑梗死发生的独立危险因素(P0.05);Hunt～Hess≥Ⅲ级和血管痉挛是迟发性脑梗死发生的独立危险因素(P0.05);早期脑梗死是术后a SHA患者长期不良预后的独立危险因素(OR,2.43;95%CI,1.16～4.72;P0.001)。结论 Hunt～Hess≥Ⅲ级和手术夹闭术是aSAH患者术后并发早期脑梗死的独立危险因素,而Hunt～Hess≥Ⅲ级和血管痉挛则是迟发性脑梗死的独立危险因素。早期脑梗死比迟发性脑梗死更能预测aSAH患者术后的不良预后。     

Abnormalities on ECG and telemetry predict stroke outcome at 3 months

BACKGROUND: ECG is a useful tool in monitoring vital functions in patients with acute stroke; however, fairly little evidence is available concerning the prevalence and the prognostic impact of ECG findings in patients with acute cerebral infarction and acute intracerebral haemorrhage (ICH). METHODS: This analysis was based on data from 692 patients with acute cerebral infarction, 155 patients with intracerebral haemorrhage (ICH), and 223 patients with transient ischaemic attack (TIA), who were admitted to hospital within 6 h of symptom onset. A 12 lead ECG was obtained on admission, and the patient was on telemetry for the first 12-24 h of hospitalisation. RESULTS: ECG abnormalities were observed in 60% of patients with cerebral infarction, 50% of patients with ICH, and 44% of patients with TIA. In multivariate analyses 3-month mortality in patients with ischaemic stroke was predicted by atrial fibrillation OR 2.0 (95% CI 1.3-3.1), atrio-ventricular block OR 1.9 (95% CI 1.2-3.9), ST-elevation OR (2.8, 95% CI 1.3-6.3), ST-depression OR 2.5 (95% CI 1.5-4.3), and inverted T-waves OR 2.7 (95% CI 1.6-4.6). This was independent of stroke severity, pre-stroke disability and age. In patients with ICH, sinus tachycardia OR 4.8 (95% CI 1.7-14.0), ST-depression OR 5.2 (95% CI 1.1-24.9), and inverted T-wave 5.2 (95% CI 1.2-22.5) predicted poor outcome. None of the changes reached significance in patients with TIA. In patients with severe cerebral infarction or ICH, heart rate did not decrease within the first 12 h after admission, which was the case in patients with mild to moderate stroke. Rapid heart rate predicted 3-month mortality in multivariate testing OR 1.7 (95% CI 1.02-2.7). CONCLUSIONS: ECG abnormalities are frequent in acute stroke and may predict 3-month mortality.     

Fatigue at long-term follow-up in young adults with cerebral infarction

BACKGROUND: To study the impact of fatigue in young ischaemic stroke patients. METHODS: The Fatigue Severity Scale score was obtained in 192 patients (mean time 6.0 years after the stroke) and 212 controls. RESULTS: Fatigue was associated with cerebral infarction in a multivariate analysis of patients and controls (p = 0.002). Fatigue was independently associated with unfavourable functional outcome (p = 0.001), depression (p < 0.001), and basilar artery infarction through interaction with the modified Rankin Scale score (p = 0.047) in patients. CONCLUSION: Fatigue is frequent in young adults with cerebral infarction. Stroke-related factors independently associated with fatigue include functional outcome. Stroke location may influence fatigue.     

Prognosis of ischaemic stroke — a multivariate analysis

Paucity of studies on the prognosis of ischaemic stroke prompted this study. Sixty-seven patients with CT-proven infarction were studied after a mean duration of 9 days to evaluate the role of a number of clinical, CT scan and evoked potential parameters in predicting the prognosis. Their mean age was 53 (range 22–82) years and 16 were females. Four of these patients died and 20 had poor recovery. Out of 24 clinical, CT scan and evoked potential parameters analysed by univariate analysis, 11 variables were found to be significant These were Canadian Neurological Scale, Glasgow Coma Scale (GCS), Motoricity Index, muscle tone, tendon reflex, incontinence, sensations, motor area involvement on CT scan, size of infarction, motor evoked potential and somatosensory evoked potential. Multivariate logistic regression analysis was employed to study the combined effect of different variables on the outcome. The best model included past history of stroke, GCS, pulse pressure and involvement of motor area on CT scan. The model proposed by us is simple and useful for predicting 3 month outcome of ischaemic stroke. A larger study is recommended to confirm these findings.-     

Microalbuminuria in patients with acute ischemic stroke

ABSTRACT

Objective: Microalbuminuria could be detected in patients with acute stroke. However, the association between microalbuminuria and the severity of ischemic stroke has not been systematically investigated. This study aimed to systematically explore the prevalence of microalbuminuria in ischemic stroke patients, and the association of microalbuminuria with the severity of ischemic stroke, as well as the prognostic value of microalbuminuria in cerebral infarction patients.

Methods: 160 ischemic stroke patients and 54 controls were enrolled and clinical characteristics were recorded. Severity of stroke was assessed by NIHSS score at admission, and outcome was measured using mRS score. The concentration of urinary microalbumin was collected for each participant. Multiple linear regression analysis was performed to evaluate the relationship between microalbuminuria and the severity of ischemic stroke, and logistic regression analysis was employed to identify the prognostic value of microalbuminuria in ischemic stroke patients.

Results: The incidence of microalbuminuria in ischemic stroke patients was 36.88%. The concentration of urinary microalbumin increased with the increasing of cerebral infarction size, and was independently correlated with NIHSS score at admission and mRS score at 3 months after onset. In multivariate logistic regression analyses, microalbuminuria was one of the independent risk factors for poor prognosis of cerebral infarction patients.

Conclusions: MAU?was?found?in?approximately?one-third of patients with acute ischemic stroke. It was correlated with the severity of cerebral infarction at admission and clinical outcomes at 3 months after onset and could be used as a potential indicator of poor prognosis in ischemic stroke patients.     

西安地区急性复发性脑梗死患者的临床特征及1年预后分析

目的 探讨西安地区急性复发性脑梗死(acute recurrent cerebral infarction,ARCI)患者的临床特征及1年预后.方法 通过西安卒中登记研究,纳入西安市4所三级甲等医院2015年1-12月连续收治的急性脑梗死患者,根据是否合并既往脑梗死病史分为急性首发脑梗死(acute first-eve...     

Raised plasma oxidised LDL in acute cerebral infarction

BACKGROUND: The association between oxidised low density lipoprotein (OxLDL) and cerebral infarction is suspected but not established. OBJECTIVES: To determine whether plasma OxLDL is a useful marker for monitoring oxidative stress in stroke patients. METHODS: Plasma OxLDL concentrations were determined in 56 stroke patients with cerebral infarction (n = 45) or cerebral haemorrhage (n = 11), and in 19 age matched controls, using a novel sandwich enzyme linked immunosorbent assay. RESULTS: Compared with the controls (0.130 (0.007) ng/ micro g LDL, mean (SEM)), OxLDL was significantly raised in patients with cerebral infarction (0.245 (0.022); p < 0.0001) but not in those with haemorrhage (0.179 (0.023)). Patients with cortical ischaemic infarcts (n = 22) had higher OxLDL levels than either the controls (p < 0.0001) or the patients with non-cortical ischaemic infarcts (n = 23) (p < 0.001). Increased OxLDL concentrations in patients with cortical infarcts persisted until the third day after stroke onset. The National Institutes of Health stroke scales in patients with cortical infarction were higher than in those with non-cortical infarction (p < 0.01). CONCLUSIONS: There is a significant association between raised plasma OxLDL and acute cerebral infarction, especially cortical infarction. Plasma OxLDL may reflect oxidative stress in stroke patients.     

Intracerebral hemorrhage versus infarction: Stroke severity,risk factors,and prognosis

The purpose of this study was to compare stroke severity, risk factors, and prognosis in patients with intracerebral hemorrhage versus infarction. We prospectively studied 1,000 unselected patients with acute stroke of a verified type in the Copenhagen Stroke Study. Neurological deficits and functional disabilities were evaluated weekly from the time of acute admission throughout the rehabilitation period. Eighty-eight (9%) had intracerebral hemorrhage. The relative frequency of intracerebral hemorrhage rose exponentially with increasing stroke severity. In multivariate analyses, stroke type had no influence on mortality, neurological outcome, functional outcome, or the time course of recovery. Initial stroke severity was the all-important prognostic factor. The relative importance of hypertension and blood pressure on admission was not greater for intracerebral hemorrhage than for infarction. No preponderance was found between type of stroke and sex, age, and smoking. Diabetes, ischemic heart disease, and elevated serum total cholesterol level all favored cerebral infarction as opposed to intracerebral hemorrhage. We conclude that the type of stroke per se has no influence on stroke prognosis in general; the extent of the injury is decisive. The poorer prognosis in patients with intracerebral hemorrhage is due to the increase in frequency of intracerebral hemorrhage with increasing stroke severity. The likelihood of cerebral infarction occuring as opposed to intracerebral hemorrhage seems increased fivefold in stroke patients with diabetes. Hypertension and blood pressure on admission were not predictors of stroke type.