Journal of Stroke & Cerebrovascular Diseases

Reevaluating Obstructive Sleep Apnea as a Risk Factor for Cerebrovascular Disease

Hrayr Attarian — 2010-09-01

Over the past quarter century, multiple studies have firmly established an association between obstructive sleep apnea syndrome (OSAS) and stroke. Case reports, case series, and case-control studies have demonstrated an ∼70% prevalence of OSAS in stroke survivors. Furthermore, the severity of OSAS (Apnea Hypopnea Index [AHI] of >30/hour) is much higher in stroke patients than in controls. In many cases, the symptoms of OSAS precede the occurrence of stroke, suggesting a cause-and-effect relationship.

Comparison of Outcomes of Nonsurgical Spontaneous Intracerebral Hemorrhage Based on Risk Factors and Physician Specialty

2010-05-26

Background: The authors report the effects of patient risk factors and physician specialty on the clinical outcomes of patients with spontaneous intracerebral hemorrhage (ICH), who were treated nonsurgically at 3 academic medical centers. To our knowledge, there is no reported literature on the effect of physician specialty and outcomes (modified Rankin scale [mRS] score, in-hospital death, and hospital length of stay [LOS]).Methods: A new patent pending data-mining method, Healthcare Smart Grid™, retrospectively analyzed hospital data for 129 patients with spontaneous ICH admitted to 3 (two university and one community) hospitals in a single metropolitan region and treated nonsurgically. Patients with traumatic hemorrhages and subarachnoid hemorrhages were excluded from the study. Demographic data, clinical presentation, medical risk factors, and hematoma characteristics were tested for associations with 3 outcomes: in-hospital death, mRS score at discharge, and LOS.Results: A total of 129 cases were identified in the university (77 cases) and community (52 cases) hospitals during a 20-month period (December 2005-July 2007). The mean age was 64.1 years with 48% being men and 83% being black. The median LOS among survivors was 6 days. LOS was significantly associated with physician specialty (P=.002 for both comparisons: neurologists and neurosurgeons with internists) and hemorrhage volume. Mortality in these patients was 23%. In an adjusted analysis, hemorrhage volume (P < .001) and Glasgow Coma Scale score at admission (P=.001) were significant predictors of in-hospital mortality, whereas physician specialty, number of comorbidities, and other risk factors were not. The median mRS score at discharge was 3. Larger hemorrhage volume tends to predict greater disability (P=.06).Conclusions: LOS for spontaneous nonsurgically treated ICH tends to be the least with admission to specialist services such as neurologists and neurosurgeons. Physician specialties do not seem to influence mRS score or mortality in medically managed spontaneous ICH. Hemorrhage volume has a statistically significant association with death and LOS.

National Institutes of Health Stroke Scale Assists in Predicting the Need for Percutaneous Endoscopic Gastrostomy Tube Placement in Acute Ischemic Stroke

2010-05-31

Percutaneous endoscopic gastrostomy (PEG) tubes are commonly needed for early nutrition in patients with acute ischemic stroke. We evaluated the relationship between the NIH Stroke Scale (NIHSS) score and the need for PEG tube placement. Patients with acute ischemic stroke were included in this study. We collected information on patient demographics, stroke severity as indicated by the NIHSS, and risk factors for vascular disease. We ascertained the swallowing evaluation and PEG tube placement during the same hospitalization. A hierarchical optimal classification tree was determined for the best predictors. A total of 187 patients (mean age, 67.2 years) were included, only 33 (17.6%) of whom had a PEG tube placed during the course of hospitalization. Those who had the PEG were slightly older (73.8 vs 65.8 years), had severe stroke (median NIHSS score, 18 vs 4), and a longer hospital stay (median 12 vs 4 days). Independent predictors for PEG placement included bulbar symptoms at onset, higher NIHSS score, stroke in the middle cerebral artery distribution, and aspiration pneumonia. Hierarchical analysis showed that patients with aspiration pneumonia and NIHSS score ≥12 had the highest likelihood (relative risk [RR] = 4.67; P < .0001) of requiring a PEG tube. In the absence of pneumonia, NIHSS score ≥16 yielded a moderate likelihood of requiring PEG (RR = 1.80; P < .0001). Our findings indicate that the presence of pneumonia and high NIHSS score are the best predictors for requiring PEG tube insertion in patients with ischemic stroke. These findings may have benefits in terms of early decision making, shorter hospitalization, and possible cost savings.

Pontine Warning Syndrome: Case Series and Review of Literature

Sombat Muengtaweepongsa, Niranjan N. Singh, Salvador Cruz-Flores — 2010-05-05

Crescendo transient ischemic attacks (TIAs) are defined as repeated frequent short-lasting episodes of focal neurologic deficit due to cerebral ischemia. The capsular warning syndrome, a subset of crescendo TIA, consists of repetitive episodes of motor dysfunction due to ischemia in the region of internal capsule. It is not clear that patients with ischemia in the pons can have a similar clinical presentation and course. We report 11 cases presenting with crescendo TIA in the form of pure motor hemiparesis or ataxic hemiparesis that later proved to have a paramedian pontine infarct. The presumed mechanism of these infarcts is penetrating basilar artery branch occlusion at their origin, also called basilar branch disease.

A Comparison of Characteristics and Resource Use Between In-hospital and Admitted Patients with Stroke

2010-06-14

Background: Although in-hospital stroke is not a common occurrence, it is important to identify what components of stroke care these patients receive. The aims of this study were to estimate the clinical characteristics, process of stroke care, and mortality in patients admitted to hospital with stroke compared with patients with in-hospital strokes.Methods: Data from a community-based stroke register (1995-2004) in an inner city multiethnic population of 271,817 in South London, United Kingdom, were analyzed.Results: From a total of 2402 patients, 291 (12.1%) had in-hospital strokes. Patients with in-hospital strokes were more likely to be incontinent, be dysphagic, have a motor deficit, and have a low level of consciousness (P < .001) compared with admitted patients with stroke. Brain imaging was carried out more frequently in admitted patients with stroke (P < .001). Access to stroke unit care was higher in admitted patients with stroke (P < .001). In-hospital patients with stroke had a longer mean length of stay (55.9 days) compared with admitted patients with stroke (37.9 days, P < .001). There were no significant differences between the groups for receipt of physiotherapy or occupational therapy after discharge (P=.232) or receipt of speech and language therapy (P=.345). After adjustment of case mix variables, in-hospital patients with stroke were less likely to undergo imaging (odds ratio [OR]=0.54, 95% confidence interval [CI]=0.33-0.89, P=.015). In-hospital patients with stroke were less likely to be treated in a stroke unit (OR=0.33, 95% CI=0.22-0.50, P < .001) and prescribed antiplatelet therapy at 3 months (OR=0.51, 95% CI=0.30-0.88, P=.015). By 3 months, in-hospital patients with stroke were more likely to have died (P < .001), although this was not significant after case mix adjustment (OR=1.39, 95% CI=0.90-2.15, P=.135).Conclusion: This study demonstrated that in-hospital patients with stroke had worse stroke severity, and poorer access to a number of components of stroke care compared with admitted patients with stroke. All hospitals should include, in their stroke policies and guidelines, evidence-based pathways that prioritize the needs of patients who have a stroke while in hospital.

Anxiety, Depression, and Psychological Well-being 2 to 5 years Poststroke

2010-05-26

Objectives: We sought to explore psychological well-being and the psychosocial situation in persons with stroke, 2 to 5 years after discharge from a specialized rehabilitation hospital.Methods: The Hospital Anxiety and Depression Scale; the 30-item General Health Questionnaire; and a questionnaire were mailed to 255 former patients.Results: A total of 64% answered (36% women), and the average age was 58 years. The Hospital Anxiety and Depression Scale identified problems in 47% (anxiety in 36% and depression in 28%) and 30-item General Health Questionnaire in 54%. About half had experienced periods of anxiety, depression, or both since discharge. Most were satisfied with support by family/friends (88%), home ward (68%), and community therapy services (57%). Marital status was as in the general population.Conclusions: Long after stroke, almost half of the investigated patients with stroke had psychiatric problems according to the questionnaires. This is higher than in the general population but is comparable with some other chronic, somatic populations in Norway.

Impact of Media on Community Awareness of Stroke Warning Signs: A Comparison Study

2010-05-17

Prompt identification of the warning signs of ischemic stroke is critical to ensure appropriate and timely treatment. We implemented a 20-week public education campaign in one media market to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older in the intervention county and a comparison county before and after the campaign to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up in the intervention county (73%-82%) but not in the comparison county (68%-69%). Respondent awareness of stroke warning signs increased significantly in the intervention county among men (68%-79%) and women (76%-84%) and among respondents aged 45 to 64 years (77%-85%) and respondents aged 65 years and older (67%-78%). There was no significant change in the proportion of respondents indicating they would call 911 if they witnessed someone having a stroke in the intervention county (81%-84%). However, after the campaign, an increased proportion of respondents in the intervention county indicated they would call 911 if they experienced sudden numbness or loss of sensation (50%-56%). Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911 for specific symptoms.

Ethnic Differences in Ischemic Stroke of Working Age in Northern Israel

Gregory Telman, Efim Kouperberg, Elliot Sprecher, David Yarnitsky — 2010-05-17

Background: There are currently no comparative data about ethnic differences in ischemic stroke in Arab and Jewish populations.Methods: Data on 727 consecutive Arab and Jewish patients of working age (≤65 years) with stroke were compared for risk profile, etiology, subtyping, and immediate functional outcome.Results: The mean age was 59.4 ± 8.2 years for the Jewish and 53.7 ± 8.6 years for the Arab patients (P = .03). Higher prevalence of diabetes was found in the Arab patients after adjustment by age, sex, and main vascular risk factors (P < .0001). After adjustment, a higher prevalence of normal transesophageal echocardiography results in the Arab population was found. Small vessel disease–related strokes were significantly more frequent in the Arab patients, whereas large vessel disease–related strokes and strokes resulting from multiple causes were significantly more frequent in the Jewish patients. No correlations were found between the high prevalence of diabetes (or any other examined factor) and the predominance of small vessel disease–related strokes in the Arab patients and large vessel disease–related strokes in the Jewish patients. There was no difference found in treatment or outcome between the Arab and the Jewish patients.Conclusions: There are substantial differences in the risk profiles and subtyping of strokes between Arab and Jewish patients of working age.

Cognitive Function and Mortality in a Community-based Elderly Cohort of First-ever Stroke Survivors and Control Subjects

Peter Hobson, Jolyon Meara — 2010-05-17

Objective: We sought to determine the frequency and incidence of cognitive impairments not dementia, dementia, and mortality in first-ever stroke survivors and control subjects.Methods: We conducted a longitudinal follow-up of a cohort of first-ever stroke survivors (n=98) and age-/sex-matched control subjects (n=92).Results: At baseline, 37 stroke survivors and 4 control subjects fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for dementia. From baseline to follow-up, 6 new patients in the nondemented stroke cohort and 4 patients in the stroke-free cohort developed dementia, giving an incidence of 3.97 (95% confidence interval [CI] 1.46-8.65) and 1.78 (95% CI 0.49-4.57), respectively. The stroke cohort had a more than 2-fold increased risk for developing dementia (relative risk=2.14, 95% CI 0.64-7.13). The cumulative rate of mortality in the stroke cohort was 11.03 per 100 person-years (95% CI 7.7-15.3) and in the stroke-free cohort it was 3.47 per 100 person-years (95% CI 1.13-8.1). The risk for mortality after controlling for dementia cases at baseline was more than 2.5 times that of the stroke-free cohort.Conclusions: A first-ever stroke increases the risk of developing dementia, Mortality in our stroke cohort was still higher than that observed in the stroke-free cohort. Improved survival poststroke may be contributing to an increased risk for cognitive impairment or dementia in this population.

A Simple Electrocardiogram Marker for Risk Stratification of Ischemic Stroke in Low-resources Settings

Elsayed Z. Soliman, Hadge Juma, Nelson Nkosi — 2010-05-17

Background: Because of economic constraints, identification of patients at high risk for ischemic stroke who may benefit from further evaluation and aggressive control of their risk factors carries a special importance in low-resources settings. We sought to examine the use of the negative component of the P wave in V1 in the standard electrocardiogram, referred to as P-wave terminal force (PTF), as a risk stratification tool of ischemic stroke in Africans living in Malawi, a sub-Saharan African country where stroke is a strongly emerging health problem.Methods: This was a case-comparison study where 92 patients with ischemic stroke were compared with an equal number of subjects in an age- and sex-matched comparison group. The sensitivity and specificity of abnormal PTF, defined as PTF greater than or equal to 4mm-s, to diagnose ischemic stroke were calculated. Univariate and multivariable logistic regression analysis was used to estimate the odds of ischemic stroke associated with abnormal PTF.Results: Abnormal PTF was present in 54% of patients with stroke compared with only 17% of the comparison group (P < .001). The specificity and sensitivity of PTF was 82% and 54%, with positive and negative predictive values of 76% and 64%, respectively. PTF was associated with ischemic stroke in a univariate analysis (odds ratio [OR] 5.7; 95% confidence interval [CI] 2.9-11.1), a multivariate analysis adjusting for common ischemic stroke risk factors (OR 2.8; 95% CI 2.4-3.4), and even with further adjustment for echocardiographically measured left atrial size (OR 2.1; 95% CI 1.9-2.4).Conclusions: PTF greater than or equal to 4mm-s is associated with the risk of ischemic stroke in Africans independently from ischemic stroke risk factors. Given its reasonable sensitivity and specificity to predict ischemic stroke, PTF greater than or equal to 4mm-s could be used as a risk stratification tool to discriminate between patients at high and low risk of ischemic stroke, and subsequently identify patients who may benefit from further evaluation and aggressive control of their risk factors.

Comparison of Clinical Backgrounds with Anterior Versus Posterior Circulation Infarcts

2010-05-17

Background: The aim of this study was to identify the relevant clinical backgrounds for anterior circulation territory infarctions (ACTI) and posterior circulation territory infarctions (PCTI).Methods: Data were obtained from April 1995 to May 2005 discharge statistics of the neurologic service in our hospital. The infarctions were divided into anterior circulation territory and posterior circulation territory by computed tomography and magnetic resonance imaging, and we examined clinical backgrounds for small vessel disease, large artery disease, and cardioembolism (CE).Results: A total of 1089 cases were ACTI and 430 were PCTI. Male/female ratio was 1.75 for ACTI and 2.67 for PCTI (P < .05). The mean age was 69.1 years for ACTI and 65.9 years for PCTI (P < .001). Multiple logistic regression analysis showed that significant contributed clinical backgrounds for small vessel disease were age and hyperlipidemia in ACTI. Those for large artery disease were male sex and history of cerebrovascular disease in PCTI. Those for CE were age and atrial fibrillation in ACTI; and diabetes, hypertension, hyperlipidemia, and smoking in PCTI. Those for all cerebral infarctions were age and atrial fibrillation in ACTI; and male sex, diabetes, and hypertension in PCTI.Conclusion: This study showed differences in clinical backgrounds between ACTI and PCTI. Moreover, PCTI were closely related to the conventional vascular risk factors even in CE.

Effect of Mastication on Functional Recoveries after Permanent Middle Cerebral Artery Occlusion in Rats

2010-05-17

Objectives: We evaluated whether solid feed is more effective for functional recoveries than liquid feed in rats with ischemic brain injury after permanent middle cerebral artery occlusion (MCAO).Methods: A total of 36 male Wistar/ST rats were subjected to MCAO or sham surgery. After MCAO or sham surgery, all rats were provided liquid feed for 14 days. Then, all rats were divided into 3 groups: the solid feeding group, the liquid feeding group, and the solid feeding group of sham. Effect of mastication on functional recoveries after permanent MCAO in rats was evaluated by the limb placement test and Morris water maze (MWM) task.Results: After surgery, limb placement test scores were equal in both MCAO groups. In the acquisition trials of MWM task, statistically significant differences in escape latency were observed between the liquid feeding group and sham groups at all days, and between the solid feeding group and sham groups at days 3 and 4 of the trials. In the probe trial, statistically significant differences in time spent were observed between the liquid feeding group and sham group. On day 5 of acquisition trials, the time spent in the periphery of the pool in MWM task was significantly different among the 3 groups.Conclusion: This study suggested that solid diet mastication could be effective for the rehabilitation of sensorimotor and learning/memory dysfunction induced by cerebral infarction.

A Cost-Effectiveness Analysis of Carotid Artery Stenting Compared With Endarterectomy

Kate C. Young, Robert G. Holloway, W. Scott Burgin, Curtis G. Benesch — 2010-07-02

Endarterectomy and angioplasty with stenting have emerged as 2 alternative treatments for carotid artery stenosis. This study's objective was to determine the cost-effectiveness of carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) in symptomatic subjects who are suitable for either intervention. A Markov analysis of these 2 revascularization procedures was conducted using direct Medicare costs (2007 US$) and characteristics of a symptomatic 70-year-old cohort over a lifetime. In the base case analysis, CAS produced 8.97 quality-adjusted life-years, compared with 9.64 quality-adjusted life-years for CEA. The incremental cost of stenting was $17,700, and thus CAS was dominated by CEA. Sensitivity analyses show that the long-term probabilities of major stroke or mortality influenced the results. In the base case analysis, CEA for patients with symptomatic stenosis has a greater benefit than CAS, with lower direct costs. With 59% probability, CEA will be the optimal intervention when all of the model assumptions are varied simultaneously.

Reliability of Proxy Respondents for Patients With Stroke: A Systematic Review

Colin Oczkowski, Martin O'Donnell — 2010-05-31

Proxy respondents are an important aspect of stroke medicine and research. We performed a systematic review of studies evaluating the reliability of proxy respondents for stroke patients. Studies were identified by searches of MEDLINE, Google, and the Cochrane Library between January 1969 and June 2008. All were prospective or cross-sectional studies reporting the reliability of proxy respondents for patients with a history of previous stroke or transient ischemic attack. One author abstracted data. For each study, intraclass correlation (ICC) or the k-statistic was categorized as poor (≤0.40), moderate (0.41-0.60), substantial (0.61-0.80), or excellent (>0.80). Thirteen studies, with a total of 2618 participants, met our inclusion criteria. Most studies recruited patients >3 months after their stroke. Of these studies, 5 (360 participants; 5 scales) evaluated reliability of proxy respondents for activities of daily living (ADL), and 9 (2334 participants; 9 scales) evaluated reliability of proxy respondents for quality of life (QoL). One study evaluated both. In studies, the ICC/k for scales ranged from 0.61 to 0.91 for ADL and from 0.41 to 0.8 for QoL. Most studies reported that proxy respondents overestimated impairments compared with patient self-reports. Stroke severity and objective nature of questions were the most consistent determinants of disagreement between stroke patient and proxy respondent. Our data indicate that beyond the acute stroke period, the reliability of proxy respondents for validated scales of ADL was substantial to excellent, while that of scales for QoL was moderate to substantial.

Masthead

2010-09-01

Editorial Board

2010-09-01

Journal of Stroke & Cerebrovascular Diseases

Reevaluating Obstructive Sleep Apnea as a Risk Factor for Cerebrovascular Disease

Comparison of Outcomes of Nonsurgical Spontaneous Intracerebral Hemorrhage Based on Risk Factors and Physician Specialty

National Institutes of Health Stroke Scale Assists in Predicting the Need for Percutaneous Endoscopic Gastrostomy Tube Placement in Acute Ischemic Stroke

Pontine Warning Syndrome: Case Series and Review of Literature

A Comparison of Characteristics and Resource Use Between In-hospital and Admitted Patients with Stroke

Anxiety, Depression, and Psychological Well-being 2 to 5 years Poststroke

Impact of Media on Community Awareness of Stroke Warning Signs: A Comparison Study

Ethnic Differences in Ischemic Stroke of Working Age in Northern Israel

Cognitive Function and Mortality in a Community-based Elderly Cohort of First-ever Stroke Survivors and Control Subjects

A Simple Electrocardiogram Marker for Risk Stratification of Ischemic Stroke in Low-resources Settings

Comparison of Clinical Backgrounds with Anterior Versus Posterior Circulation Infarcts

Effect of Mastication on Functional Recoveries after Permanent Middle Cerebral Artery Occlusion in Rats

A Cost-Effectiveness Analysis of Carotid Artery Stenting Compared With Endarterectomy

Reliability of Proxy Respondents for Patients With Stroke: A Systematic Review

Masthead

Editorial Board

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