Pre-hospital delays and intravenous thrombolysis in urban and rural areas

Kozera G, Chwojnicki K, Gójska‐Grymaj?o A, G?secki D, Schminke U, Nyka WM. Pre‐hospital delays and intravenous thrombolysis in urban and rural areas.
Acta Neurol Scand: 2012: 126: 171–177.
© 2011 John Wiley & Sons A/S. Introduction– It is crucial to understand the reasons behind pre‐ and in‐hospital delays to improve nationwide access to effective treatment for acute stroke. Aims– To evaluate the pre‐ and in‐hospital delays and to compare the intravenous (IV) thrombolysis rates in the urban and rural areas of the Province of Pomerania, Poland. Materials & methods– We evaluated the medical records of 2134 patients treated in the stroke units (SUs) and consecutively reported to the Pomeranian Stroke Register from June 2006–December 2007. Results– The time of ischaemic stroke onset was known in 488 (59%) of the 834 urban patients and in 744 (70%) of the 1063 rural patients (P < 0.001). The proportion of patients who called the emergency medical services with a delay of >45 min was similar in both locations: urban, 314/488 (64.3%) vs rural, 490/744 (65.8%). Although the proportion of patients who reached the emergency room within 3 h was higher in the rural areas (29.0% vs 24.3%; P = 0.02), only 4.2% of these patients received IV thrombolysis compared with 23.1% in the urban areas (P < 0.001). The proportion of patients who did not seek any kind of professional medical help prior to admission was lower in the rural areas (29/744 (3.9%) vs urban 50/488 (10.2%)) (P < 0.001). Conclusions– Pre‐hospital delays reduced the number of patients eligible for IV thrombolysis in both rural and urban areas. The low proportion of patients treated with IV thrombolysis in rural SUs may be attributed to ineffective in‐hospital procedures.     

Thrombolysis as a factor associated with favorable outcomes in patients with unclear‐onset stroke

Background and purpose: Clinical and radiological features of patients with unclear‐onset stroke do not differ significantly from those with known‐onset stroke. There is a lack of evidence for the safety and efficacy of thrombolysis in patients with unclear‐onset stroke. We sought to provide supportive data on the safety and efficiency of thrombolysis in patients with unclear‐onset stroke. Methods: We retrospectively identified patients with unclear‐onset stroke (<3 h of first found abnormal time) from our stroke registry. We performed following protocols for thrombolysis in patients with unclear‐onset stroke; initial conventional CT‐based intravenous thrombolysis (IVT), repeat MRI during IVT, and then decision to maintain IVT or to perform combined intra‐arterial thrombolysis. In addition, we compared clinical outcomes and safety between thrombolyzed and non‐thrombolyzed patients. Results: A total of 78 patients with unclear‐onset stroke were included. Twenty‐nine patients underwent thrombolysis. Thrombolysis (OR, 6.842; 95% CI, 1.950–24.004; P = 0.003) and baseline NIHSS (OR, 0.769; 95% CI, 0.645–0.917; P = 0.003) were associated with favorable outcomes at 3 months in multivariate logistic regression analysis. The frequency of hemorrhagic transformation and symptomatic ICH was not significantly different between the thrombolyzed and non‐thrombolyzed patients (34.4% vs. 40.7% and 10.3% vs. 8.2%, respectively). Conclusion: The results of this study suggest that thrombolysis in unclear‐onset stroke could be independently associated with favorable outcomes at 3 months and that thrombolysis based on repeat imaging appears to be safely applied to patients with unclear‐onset stroke.     

European Academy of Neurology and European Stroke Organization consensus statement and practical guidance for pre‐hospital management of stroke

Background and purpose

The reduction of delay between onset and hospital arrival and adequate pre‐hospital care of persons with acute stroke are important for improving the chances of a favourable outcome. The objective is to recommend evidence‐based practices for the management of patients with suspected stroke in the pre‐hospital setting.

Methods

The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to define the key clinical questions. An expert panel then reviewed the literature, established the quality of the evidence, and made recommendations.

Results

Despite very low quality of evidence educational campaigns to increase the awareness of immediately calling emergency medical services are strongly recommended. Moderate quality evidence was found to support strong recommendations for the training of emergency medical personnel in recognizing the symptoms of a stroke and in implementation of a pre‐hospital ‘code stroke’ including highest priority dispatch, pre‐hospital notification and rapid transfer to the closest ‘stroke‐ready’ centre. Insufficient evidence was found to recommend a pre‐hospital stroke scale to predict large vessel occlusion. Despite the very low quality of evidence, restoring normoxia in patients with hypoxia is recommended, and blood pressure lowering drugs and treating hyperglycaemia with insulin should be avoided. There is insufficient evidence to recommend the routine use of mobile stroke units delivering intravenous thrombolysis at the scene. Because only feasibility studies have been reported, no recommendations can be provided for pre‐hospital telemedicine during ambulance transport.

Conclusions

These guidelines inform on the contemporary approach to patients with suspected stroke in the pre‐hospital setting. Further studies, preferably randomized controlled trials, are required to examine the impact of particular interventions on quality parameters and outcome.     

Eligibility for recombinant tissue plasminogen activator in acute ischemic stroke: way to endeavor

BACKGROUND: The eligibility for recombinant tissue plasminogen activator (rtPA) is rare. We analyze the reasons for exclusion from rtPA among patients who were admitted to our hospital within 3 h. METHODS: A strict protocol for hyperacute stroke was set in a university teaching hospital. Consecutive patients activating the protocol from June 2004 to October 2005 were prospectively registered and entered into a computerized database. The patients were excluded from rtPA according to the modified exclusion criteria from the National Institute of Neurological Disorders and Stroke rtPA trial. RESULTS: Of the 182 patients activating the protocol, only 11 (6.04%) received intravenous rtPA and 4 (2.2%) IA thrombolysis. Patients were excluded for multiple reasons, and the main reasons for exclusion were minor or improving stroke (46.15%), hypertension (35.16%), insufficient time to complete studies or onset beyond 3 h after reconfirmation (24.17%) and intracranial hemorrhage (15.93%). Of 167 excluded patients, 72 (43.11%) were excluded by a single criterion, 53 (31.73%) by 2 criteria and 29 (17.36%) by 3 criteria. The mean time from hospital arrival to presentation to a neurologist was 9.24 +/- 15.11 min (n = 164, median = 8.00, mode = 10, range = 0-65). The mean time from hospital arrival to computed tomography (CT) was 21.67 +/- 23.95 min (n = 167, median = 20.00, mode = 10, range = 4-68). CONCLUSION: An intrahospital stroke code was implemented to minimize intrahospital delay. However, only 11 patients received intravenous rtPA and 4 IA thrombolysis at our hospital from June 2004 to October 2005. The result brings into question the neurologist's conservative interpretation of the criteria and the necessity to clearly define some criteria. Furthermore an intrahospital stroke code should also be implemented for inpatients to maximize the eligibility for rtPA.     

Late Hospital Arrival for Thrombolysis after Stroke in Southern Portugal: Who Is at Risk?

Background: Delayed hospital arrival remains the main reason for the low rates of thrombolysis in eligible acute ischemic stroke (AIS) patients. The role of socioeconomic and clinical factors for the prehospital delay of AIS remains poor and has never been studied in Portugal. Objectives: Describe the socioeconomic and clinical factors leading to delayed hospital admission of AIS patients eligible to thrombolysis. Methods: A case-control study with a consecutive thrombolyzed AIS patients from 2010 to 2015. Controls were patients who did not receive thrombolysis because of late hospital arrival. Logistic regression with stepwise forward regression analysis was used to identify independent predictors of delayed admission to receive thrombolysis with intravenous tissue-type plasminogen activator (rtPA). Results: Of the 1247 patients admitted with AIS, 76 (6%) arrived on-time and received intravenous rtPA. Controls were 65.8% (146/222) of the total number of patients included in the study. Overall, the mean age was 73 years (±11, 61), a minority were below 60 years, and 43.7% were women. Being beneficiary of social insertion income (odds ratio [OR]: .286; .124-.662, P?=?.003), not having any telephone contact (OR: .145; .039-.536, .004) or having exclusive landline (.055; .014-.210, <.001) and posterior circulation stroke (OR: .266; .087-.811, P?=?.020) decreased the likelihood of hospital arrive on-time rtPA. The use of prehospital ambulance services increased (OR: 6.478; 2.751-15.254, P < .001) the odds of ER on-time arrival for thrombolysis. Conclusions: Poverty, lack of stroke awareness, or difficulties in requesting immediate medical help are the main factors implicated in late-hospital admission for thrombolysis in AIS. Stroke awareness campaigns, promotion of activation of national emergency number and stroke code can increase the rate of thrombolysis.     

Safety and Efficacy of Reperfusion Therapies for Acute Ischemic Stroke Patients with Active Malignancy

Background and Purpose: Epidemiological correlations between active malignancy (AM) and acute ischemic stroke (AIS) are well-established. However, the effect of reperfusion strategies, particularly mechanical thrombectomy (MT), has been barely investigated in patients with AIS and AM. We aim to evaluate safety and efficacy of reperfusion strategies in such patients. Materials and Methods: We performed a case-control analysis comparing patients with AM and AIS (AM group) to a group of cancer-free patients with AIS (control group). All enrolled patients underwent reperfusion therapies (i.e. intravenous thrombolysis, MT, intravenous thrombolysis plus MT). Main outcomes were 3-month functional independence, successful reperfusion, 3-month mortality, symptomatic intracranial hemorrhage. Results: Total 24 patients with AM and AIS (mean age: 69 ± 10.1) were individually matched to 24 control patients (mean age: 70.7 ± 9.3). In both groups 50% were treated with MT, 46% with intravenous thrombolysis and 4% with intravenous thrombolysis plus MT. No difference were found in successful reperfusion, 3-month functional independence, symptomatic intracranial hemorrhage, and mortality. However an overall mortality of 33% in the AM group was reported. Conclusions: Reperfusion strategies for AIS patients with AM seem to be safe and effective. However an individualized approach to understand cancer stage and life-expectation is warranted.     

In‐hospital stroke: a multi‐centre prospective registry

Background: In‐hospital strokes (IHS) are relatively frequent. Avoidable delays in neurological assessment have been demonstrated. We study the clinical characteristics, neurological care and mortality of IHS. Methods: Multi‐centre 1‐year prospective study of IHS in 13 hospitals. Demographic and clinical characteristics, admission diagnosis, quality of care, thrombolytic therapy and mortality were recorded. Results: We included 273 IHS patients [156 men; 210 ischaemic strokes (IS), 37 transient ischaemic attacks (TIA) and 26 cerebral haemorrhages]. Mean age was 72 ± 12 years. Cardiac sources of embolism were present in 138 (50.5%), withdrawal of antithrombotic drugs in 77 (28%) and active cancers in 35 (12.8%). Cardioembolic stroke was the most common subtype of IS (50%). Reasons for admission were programmed or urgent surgery in 70 (25%), cardiac diseases in 50 (18%), TIA or stroke in 30 (11%) and other medical illnesses in 71 (26%). Fifty‐two per cent of patients were evaluated by a neurologist within 3 h of stroke onset. Thirty‐three patients received treatment with tPA (15.7%). Thirty‐one patients (14.7%) could not be treated because of a delay in contacting the neurologist. During hospitalization, 50 patients (18.4%) died, 41 of them because of the stroke or its complications. Conclusions: Cardioembolic IS was the most frequent subtype of stroke. Cardiac sources of embolism, active cancers and withdrawal of antithrombotic drugs constituted special risk factors for IHS. A significant proportion of patients were treated with thrombolysis. However, delays in contacting the neurologist excluded a similar proportion of patients from treatment. IHS mortality was high, mostly because of stroke.     

Low free triiodothyronine levels are related to symptomatic intracranial hemorrhage and poor functional outcomes after intravenous thrombolysis in acute ischemic stroke patients

Background and Objective: Low free triiodothyronine (fT3) levels have been associated with increased mortality and poor functional outcomes in patients with stroke. However, the research of relationship between fT3 levels and acute ischemic stroke (AIS) patients with intravenous thrombolysis (IVT) is scarce. We aimed to investigate the association of fT3 levels with symptomatic intracranial hemorrhage (sICH) and functional outcomes at discharge in AIS patients with IVT.

Methods: Patients with AIS admitted to West China hospital, Sichuan University, who had underwent IVT treatment, were consecutively and retrospectively included. Demographic and clinical information were collected and analyzed according to the levels of fT3. We used logistic regression analysis to estimate the multivariable adjusted association of fT3 levels and post-IVT sICH, and functional outcomes at discharge.

Results: Among the 46 patients (26 males; mean age, 63.6 years) in the final analysis, 17 patients (37.0%) had fT3 levels lower than the reference range. After adjustment for age, gender, and statistically important variables (NIHSS on admission, urea levels and creatinine levels), low fT3 levels were significantly associated with post-IVT sICH (p = 0.01, OR = 0.27, 95% CI 0.10–0.77) and poor functional outcomes at discharge (p = 0.04 OR = 2.58, 95% CI 1.05–6.35).

Conclusion: We found that lower free T3 levels are independently related to post-IVT sICH and poor functional outcomes at discharge in AIS patients with IVT, which should be verified and extended in large cohorts in the future.     

Off‐hour effects on stroke care and outcome in stroke centres

Background and purpose: Poorer stroke care processes and outcomes have been reported for acute stroke patients arriving at centres during off hours and weekends. Objective: To compare each step of the continuous specialized care that Stroke Centres (SC) provide according to time of admission and final outcome. Methods: Observational study of consecutive stroke patients admitted to SC during 2008 and 2009. Patients were classified into two groups according to their arrival time: Work Hours (WH) and Off Hour (OH) (weekends and any time other than 8:00 am to 3:00 pm on weekdays). Differences in time to diagnostic procedures, tPA administration, stroke outcome [modified Rankin Scale, (mRS)] and in‐hospital fatality rates were analysed. Results: A total of 912 patients were admitted. Data from 674 patients fulfilling study criteria were analysed. A total of 434 (64.4%) patients arrived during OH. No differences in stroke severity were found when comparing OH and WH. Time to blood test results was higher for WH (median 67 min vs. 47 min; P < 0.01), but time to cranial CT scan was similar. Intravenous tPA was administered to 58 (16.4%) OH vs. 26 (13.1%) WH patients (P = 0.33). OH arrival was not associated with poorer outcome (mRS ≥ 3) at discharge (32.8% vs. 37%; P = 0.27), or at the 3‐month follow‐up (30.6% vs. 27.6%, P = 0.52). No differences were found for in‐hospital fatality rates (5.8% vs. 5.4%, P = 1.00). Conclusions: The care provided by SC with neurologists on call 24/7 prevents differences in outcomes associated with time of admission and guarantees equal attention to stroke patients.     

Increasing use of intravenous rt–PA does not affect safety in acute stroke

Background Intravenous thrombolysis with rt–PA improves outcome in acute ischemic stroke. In a prospective study we analyzed the annual frequency of rt–PA treatment, its safety, and early clinical outcome. Methods All patients admitted to our stroke unit (SU) from 1998 to 2003 were registered in a prospective data base. Documented data included patient age, sex, time interval until admission, initial therapy (e. g., thrombolysis), death, intracerebral hemorrhage, other complications, and score on the National Institute of Health Stroke Scale (NIHSS). Results From 1998 to 2003, a total of 112 patients were treated with systemic thrombolysis. The number of acute stroke patients admitted within 2.5 hours and therefore eligible for thrombolysis did not substantially change between 1998 and 2003. From 1998 to 2001 the percentage of acute stroke patients that received rt–PA was stable (12.6–16.9 %). This percentage increased in 2002 (29.6%, p<0.05) and, again, in 2003 (42.1%, p<0.01). Of all treated patients, two developed symptomatic intracerebral hemorrhage (1.8%) and five died three to seven days after thrombolysis (4.5 %). The NIHSS score of patients receiving rt–PA significantly decreased during the acute treatment phase (14.2±5.1 to 8.0±5.9, p<0.001). A comparison of single years revealed that this NIHSS score reduction was stable. Conclusion In our selected patients, the proportion of acute stroke patients treated with systemic thrombolysis increased almost three–fold from 1998 to 2003. This may be explained by protocol modifications and growing experience with the use of rt–PA. Our data demonstrate that increased use of rt–PA in acute stroke patients can be achieved without adversely affecting safety or clinical benefit.     

Structural connectome disruption at baseline predicts 6‐months post‐stroke outcome

In this study, models based on quantitative imaging biomarkers of post‐stroke structural connectome disruption were used to predict six‐month outcomes in various domains. Demographic information and clinical MRIs were collected from 40 ischemic stroke subjects (age: 68.1 ± 13.2 years, 17 female, NIHSS: 6.8 ± 5.6). Diffusion‐weighted images were used to create lesion masks, which were uploaded to the Network Modification (NeMo) Tool. The NeMo Tool, using only clinical MRIs, allows estimation of connectome disruption at three levels: whole brain, individual gray matter regions and between pairs of gray matter regions. Partial Least Squares Regression models were constructed for each level of connectome disruption and for each of the three six‐month outcomes: applied cognitive, basic mobility and daily activity. Models based on lesion volume were created for comparison. Cross‐validation, bootstrapping and multiple comparisons corrections were implemented to minimize over‐fitting and Type I errors. The regional disconnection model best predicted applied cognitive (R² = 0.56) and basic mobility outcomes (R² = 0.70), while the pairwise disconnection model best predicted the daily activity measure (R² = 0.72). These results demonstrate that models based on connectome disruption metrics were more accurate than ones based on lesion volume and that increasing anatomical specificity of disconnection metrics does not always increase model accuracy, likely due to statistical adjustments for concomitant increases in data dimensionality. This work establishes that the NeMo Tool's measures of baseline connectome disruption, acquired using only routinely collected MRI scans, can predict 6‐month post‐stroke outcomes in various functional domains including cognition, motor function and daily activities. Hum Brain Mapp, 2016. © 2016 Wiley Periodicals, Inc .     

Prehospital Notification from the Emergency Medical Service Reduces the Transfer and Intra-Hospital Processing Times for Acute Stroke Patients

Background and Purpose

There is little information available about the effects of Emergency Medical Service (EMS) hospital notification on transfer and intrahospital processing times in cases of acute ischemic stroke.

Methods

This study retrospectively investigated the real transfer and imaging processing times for cases of suspected acute stroke (AS) with EMS notification of a requirement for intravenous (IV) tissue-type plasminogen activator (t-PA) and for cases without notification. Also we compared the intra-hospital processing times for receiving t-PA between patients with and without EMS prehospital notification.

Results

Between December 2008 and August 2009, the EMS transported 102 patients with suspected AS to our stroke center. During the same period, 33 patients received IV t-PA without prehospital notification from the EMS. The mean real transfer time after the EMS call was 56.0±32.0 min. Patients with a transfer distance of more than 40 km could not be transported to our center within 60 min. Among the 102 patients, 55 were transferred via the EMS to our emergency room for IV t-PA. The positive predictive value for stroke (90.9% vs. 68.1%, p=0.005) was much higher and the real transfer time was much faster in patients with an EMS t-PA call (47.7±23.1 min, p=0.004) than in those without one (56.3±32.4 min). The door-to-imaging time (17.8±11.0 min vs. 26.9±11.5 min, p=0.01) and door-to-needle time (29.7±9.6 min vs. 42.1±18.1 min, p=0.01) were significantly shorter in the 18 patients for whom there was prehospital notification and who ultimately received t-PA than in those for whom there was no prehospital notification.

Conclusions

Our results indicate that prehospital notification could enable the rapid dispatch of AS patients needing IV t-PA to a stroke centre. In addition, it could reduce intrahospital delays, particularly, imaging processing times.     

Influence of antiplatelet pre‐treatment on the risk of intracranial haemorrhage in acute ischaemic stroke after intravenous thrombolysis

Background: Pre‐treatment with antiplatelet agents (AP) is present amongst 30% of acute stroke patients. Previous studies have shown conflicting results on the effect of these drugs regarding haemorrhagic transformation after thrombolytic therapy. The hypothesis that pre‐treatment with AP may increase the risk of cerebral haemorrhage (ICH) after intravenous tissue plasminogen activator (tPA) was assessed. Methods: Retrospective study of consecutive prospectively registered patients with acute ischaemic stroke treated with iv tPA (n = 235) in the last 5 years. Baseline characteristics and prior AP therapy were registered on admission. Computed tomography (CT) scan was performed on admission and 24–36 h after tPA. ICH was classified according to the ECASS II criteria into haemorrhagic infarction and parenchymal haematoma (PH). Symptomatic intracerebral haemorrhage (SICH) was defined as a worsening of ≥ 4 points in the NIHSS score during the first 36 h in any haemorrhage subtype. Results: Seventy‐two (30.6%) patients were pre‐treated with AP (55 aspirin, 14 clopidogrel, 2 aspirin + clopidogrel, 1 triflusal). PH was observed in 33 (14.1%) patients (PH1 13, PH2 12, PHr 8) of whom 16 were symptomatic. Male gender (78.8% vs. 21.2%, P = 0.036), prior AP therapy (54.5% vs. 26.9%, P = 0.001), stroke severity (median NIHSS, 17 vs. 12, P = 0.005) and early CT signs of infarction (12.5% vs. 2.1%, P = 0.004) were associated with PH. The adjusted odds ratios of PH for patients pre‐treated with AP therapy was 3.5 (1.5–7.8, P = 0.002) and for SICH 1.9 (0.6–5.9, P = 0.2). Conclusions: Pre‐treatment with AP is associated with an increased risk of PH after intravenous thrombolysis in patients with acute ischaemic stroke.     

Outcome of intracerebral haemorrhage patients pre‐treated with statins

Background: Statins treatment may have potential clinical impact in vascular disease beyond cholesterol lowering. Its benefits have been documented in cerebral ischaemia and in subarachnoid haemorrhage. In intracerebral haemorrhage (ICH), experimental models in statin‐treated animals have better outcome than non‐treated ones, but in humans the relationship is unclear. We investigated whether patients treated with statins before the onset of intracerebral haemorrhage have a better outcome at 3 months than patients without statins pre‐treatment. Methods: Retrospective review of primary intracerebral haemorrhage case series from a prospective stroke register. We recorded demographics, vascular risk factors, previous statin treatment, Glasgow coma scale (GCS) at onset, ICH scale, hematoma volume and location, ventricular extension of the hematoma, and functional outcome at 3 months. The effect of prior statin treatment on good outcome (modified Rankin scale [mRS] 0 to 2) was analysed by logistic regression analysis. Results: We included 269 patients (age 71.9 ± 12.4, mean ± SD, 152 males). Thirty‐four patients (12.6%) were on prior statin treatment when admitted. There were no differences in fasting serum cholesterol and triglycerides levels between the statin pre‐treated groups and the group without statin pre‐treatment. Multivariate regression analysis showed a significant association between age (OR: 0.95; CI 0.92–0.97), ICH volume (OR: 0.96; CI 0.94–0.98), GCS (OR: 1.55; CI 1.21–1.98), pre‐treatment with statins (OR: 4.21; CI 1.47–12.17; P = 0.008), and good outcome at 3 months. Conclusions: Statins pre‐treatment of patients with intracerebral haemorrhage may provide better functional outcome at 3 months of acute onset.     

Cerebral vasomotor reactivity and dementia after ischemic stroke

Gur AY, Gücüyener D, Korczyn AD, Üzüner N, Gilutz Y, Özdemir G, Bornstein NM. Cerebral vasomotor reactivity and dementia after ischemic stroke.
Acta Neurol Scand: 2010: 122: 383–388.
© 2010 The Authors Journal compilation © 2010 Blackwell Munksgaard. Objectives – Cerebral hemodynamic features of patients with post‐stroke dementia (PSD) are still obscure. We compared cerebral vasomotor reactivity (VMR) assessed in the acute phase of ischemic stroke (IS) in patients with and without PSD. VMR was also assessed and compared in demented and non‐demented patients in the late phase of IS. Materials and methods – VMR was assessed by transcranial Doppler and the Diamox test (1 g acetazolamide i.v.). PSD was confirmed by the National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et I’Enseignement en Neurosciences (NINDS‐AIREN) and the Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV) criteria. VMR% values were compared to verify correlation with dementia. Results – Thirty patients with acute IS (AIS) were studied and followed for 3–6 months. An additional group of 37 patients was studied in the late post‐stroke period (PIS). VMR% values in the AIS groups with and without PSD were similar (25.3 ± 20.3% and 36.5 ± 22.4%, respectively, NS). The mean VMR% in the PIS groups with and without PSD were similar (32.3 ± 19.5% and 41.2 ± 24.8%, respectively, NS). Conclusions – VMR cannot predict the development of dementia after AIS and cannot identify patients with dementia in the late phase of stroke.     

Interleukin‐6 and silent cerebral infarction in hemodialysis patients: a cross‐sectional study

Background: In patients with chronic renal failure undergoing hemodialysis (HD), silent cerebral infarctions (SCI) are associated with high mortality. Levels of interleukin‐6 (IL‐6) increase with renal dysfunction and may be a novel predictor for cerebrovascular events. We tested the hypothesis that increased IL‐6 levels correlate with the occurrence of SCI in HD patients. Methods: Using cranial magnetic resonance imaging findings, we divided 50 Japanese patients undergoing HD into two groups: with SCI (60 ± 7 years, mean ± SD, n = 27) and without SCI (60 ± 6 years, n = 23). We compared the gender, body mass index, metabolic profiles, IL‐6 levels, and smoking habits between the two groups. Results: We made the following observations: (i) The prevalence of diabetes or hypertension did not differ between the two groups, (ii) the level of IL‐6 was higher in the with‐SCI group than in the without‐SCI group (P < 0.0001), (iii) the proportion of smokers was higher in the with‐SCI group (P < 0.05), (iv) plasma level of high‐density lipoprotein cholesterol was lower, whilst uric acid level was higher, in the with‐SCI group (P < 0.05 and P < 0.05, respectively), and (v) multiple logistic regression analysis identified IL‐6 levels as being significantly associated with the presence of SCI (odds ratio 3.13, 95% CI = 1.42–7.89, P < 0.0001). Conclusions: This study indicates that patients with chronic renal failure who are maintained on HD exhibit an increased prevalence of SCI and that IL‐6 is significantly associated with the presence of SCI in HD patients.     

Pre‐stroke use of beta‐blockers does not affect ischaemic stroke severity and outcome

Background and purpose: It is unclear whether pre‐stroke beta‐blockers use may influence stroke outcome. This study evaluates the independent effect of pre‐stroke use of beta‐blockers on ischaemic stroke severity and 3 months functional outcome. Methods: Pre‐stroke use of beta‐blockers was investigated in 1375 ischaemic stroke patients who had been included in two placebo‐controlled trials with lubeluzole. Stroke severity was assessed by either the National Institute of Health Stroke Scale (NIHSS) or the European Stroke Scale (ESS). A modified Rankin scale (mRS) score of >3 at 3 months was used as measure for the poor functional outcome. Results: Two hundred and sixty four patients were on beta‐blockers prior to stroke onset, and 105 patients continued treatment after their stroke. Pretreatment with beta‐blockers did not influence baseline stroke severity. There was no difference in stroke severity between nonusers and those on either a selective beta₁‐blocker or a non‐selective beta‐blocker. The likelihood of a poor outcome at 3 months was not influenced by pre‐stroke beta‐blocker use or beta‐blocker use before and continued after stroke onset. Conclusions: Pre‐stroke use of beta‐blockers does not appear to influence stroke severity and functional outcome at 3 months.     

早期就诊的急性缺血性卒中病人未溶栓原因分析

目的:研究6小时内到达医院就诊的急性缺血性脑卒中未进行溶栓治疗的原因。方法:通过对实施急性脑血管病急诊绿色通道1年期间,发病6小时内就诊的患者未进行溶栓治疗的原因进行分析。结果:166例缺血性脑卒中患者在发病6小时内经急诊绿色通道就诊,81例符合溶栓条件的患者中47例接受溶栓治疗,占符合溶栓条件患者28.31%。溶栓患者平均发病时间(211.70±86.10)min,NIHSS评分10(范围5～22)。静脉溶栓25例,动脉溶栓22例。从发病至静脉溶栓平均开始时间为(55.48±26.01)min,明显短于动脉溶栓平均开始时间(86.59±40.40)min(P=0.003)。119例未进行溶栓治疗患者中不符合条件85例,符合条件而未溶34例(占20.48%)。发病6小时内就诊的患者未溶栓的原因有神经功能障碍轻或明显改善、早期显示病灶、脑栓塞以及家属或患者拒绝。结论:发病6小时内就诊的患者未进行溶栓的可调整原因主要是家属或患者拒绝。加强公众对脑卒中的了解及接受程度有助于提高溶栓比例。     

Expression of stromal‐cell‐derived factor‐1 (SDF‐1): a predictor of ischaemic stroke?

Background and purpose: Platelet stromal‐cell‐derived factor‐1 (SDF‐1) plays a pivotal role in angiogenesis and the regeneration of ischaemic tissue through the regulation of haematopoietic progenitor cells and is upregulated at the sites of vascular injury and platelet activation. Thus, SDF‐1 has recently been discussed as a predictor in ischaemic diseases such as acute myocardial infarction. However, no clinical data pertinent to the investigation of the platelet SDF‐1 expression in patients with stroke are available. Methods: We consecutively evaluated 196 patients who were admitted to the stroke unit with symptoms suspected for stroke. Surface expression of the platelet activation markers (P‐selectin and GPIb) and the expression of platelet‐bound SDF‐1 were determined by two‐colour whole blood flow cytometry. Results: Patients with transient ischaemic attack (TIA) as well as with ischaemic stroke showed similar levels of SDF‐1 expression on hospital admission compared with patients with non‐ischaemic (NI) events and with 30 healthy controls (TIA (mean fluorescence intensity ± SD): 31.5 ± 18.2 vs. NI: 26.4 ± 15.7; P = 0.361; stroke: 28.7 ± 19.8 vs. NI; P = 0.943; control: 26.1 ± 11.3; P > 0.05 compared with all). Platelet SDF‐1 expression showed a trend with the severity of stroke according to National Institute of Health Stroke Scale score (r = 0.125; P = 0.085), but significantly correlated with the peak levels of C‐reactive protein (r = 0.218; P = 0.002) and with the levels of platelet activation (P‐selectin: r = 0.389; P = 0.001). Multifactorial analysis of covariance revealed a significant influence on platelet SDF‐1 expression by smoking (P = 0.019). Conclusions: Platelet SDF‐1 surface expression did not show any significant difference in patients with TIA and ischaemic stroke compared with patients with NI events. Thus, single biomarker evaluation of platelet SDF‐1 surface expression is not helpful to predict ischaemic stroke.     

Recovery in personal care related to cognitive impairment before and after stroke – a 1‐year follow‐up

Cederfeldt M, Gosman‐Hedström G, Gutiérrez Pérez C, Sävborg M, Tarkowski E. Recovery in personal care related to cognitive impairment before and after stroke – a 1‐year follow‐up.
Acta Neurol Scand: 2010: 122: 430–437.
© 2010 The Authors Journal compilation © 2010 Blackwell Munksgaard. Objective – To examine whether there were any differences in the recovery in performance of personal activities of daily living (P‐ADL) in elderly persons in relation to cognitive impairments pre‐ and post‐stroke from discharge to 6 and 12 months in elderly persons. Methods – Forty‐five elderly persons after stroke were assessed at discharge from hospital and at 6 and at 12 months after stroke onset. A questionnaire posed to the next of kin was used to evaluate the person’s pre‐ and post‐stroke cognitive status. P‐ADL was assessed with the Barthel Index. The Mini Mental State Examination and neuropsychological tests were used to measure cognitive functions after stroke. The National Institute of Health Stroke Scale was used to measure neurological deficits. Results – Persons with cognitive impairments before and after stroke did not improve in P‐ADL from the acute phase until 6 and 12 months, while persons with intact cognition pre‐ and post‐stroke did. Conclusion – Since cognitive problems pre‐ and post‐stroke hinder recovery in P‐ADL, it is important to understand the connection between cognitive impairment and activity limitations when planning the optimal rehabilitation, which could include special compensation strategies, learnt by the patients, cognitive assistive devices and/or appropriate personal support trained in meaningful activities in daily life in their natural environment.