Predicting cerebral edema in ischemic stroke patients.

OBJECTIVES: To produce a scoring system for predicting the development of edema in ischemic stroke patients without edema on admission. METHODS: This retrospective study included 572 ischemic stroke patients (73.3 ± 13.0 years, 300 male) without signs of cerebral edema on the first CT scan, which was performed on admission. Another scan was normally performed 3 days later, and subsequently whenever needed. Edema was defined as cerebral hypodensity with compression of lateral ventricles. The main clinical, laboratory, and instrumental variables obtained during the first 24 h were related to the appearance of edema on the CT scans performed after the first one. RESULTS: Cerebral edema occurred in 158 patients (27.6%) after a median time of 4 days. The variables independently associated with edema development were (odds ratio, 95% CI) the following: (1) total anterior circulation syndrome (4.20, 2.55-6.93; P < 0.0001), (2) hyperdense appearance of middle cerebral artery (4.12, 2.03-8.36; P = 0.0001), (3) closed eyes (2.53, 1.39-4.60; P = 0.002), (4) vomiting (3.53, 1.45-8.60; P = 0.006), (5) lacunar cerebral syndrome (0.36, 0.17-0.77; P = 0.008); and (6) white matter lesions (0.53, 0.33-0.86; P = 0.01). Counting one positive point for the first four variables and one negative point for the last two variables, a scoring system (E-score) was built. Cerebral edema could be predicted when the score was ≥ 1 (positive predictive value 61.6%, specificity 85.3%, sensitivity 62.0%). The area under the receiver operating characteristic curve was 0.78. CONCLUSIONS: In ischemic stroke patients, six variables obtained during the first 24 h of hospitalization were predictive of subsequent cerebral edema development.

Congenital Solitary Kidney in Children: Size Matters.

PURPOSE: We assessed renal function outcome in children with congenital solitary kidney and evaluated prognostic risk factors. MATERIALS AND METHODS: We retrospectively studied the clinical charts of 210 children presenting with congenital solitary kidney at 2 pediatric nephrology and 5 pediatric units between January 2009 and October 2012. Children 0 to 18 years old with a congenital solitary kidney confirmed by scintigraphy were enrolled. Of the patients 146 were suitable for analysis. Median followup was 4.6 years. Primary outcome was decreased estimated glomerular filtration rate, and secondary outcome was occurrence of proteinuria and/or systemic hypertension. Primary outcome-free survival analysis was performed, including multiple regression analysis of significant risk factors. RESULTS: Decreased estimated glomerular filtration rate was present in 12% of children at a median age of 2.2 years. Primary outcome-free survival analysis revealed an estimated event-free survival of 82% (95% CI 74% to 91%) at 10 years. Estimated survival rate was significantly decreased in children with additional congenital anomalies of the kidney/urinary tract (54% vs 88% overall) or insufficient renal length vs expected for normal congenital solitary kidney. The latter was the strongest predictor of decreased estimated outcome-free survival (49% vs 89%, p <0.001). Occurrence of proteinuria and/or systemic hypertension was present in less than 5% of children. CONCLUSIONS: Some children with congenital solitary kidney show decreased glomerular filtration rate. Associated anomalies of the kidney/urinary tract and insufficient renal length appear to be significant risk factors. Adequate length of the congenital solitary kidney is a key parameter for maintenance of renal function and should be examined routinely during followup.

Combination of the clock drawing test with the physical phenotype of frailty for the prediction of mortality and other adverse outcomes in older community dwellers without dementia.

BACKGROUND: Cognitive assessment is thought to increase the ability of the physical phenotype of frailty to identify older persons at a higher risk for adverse outcomes. OBJECTIVE: Data from a cohort of dementia-free community dwellers were used to investigate whether the clock drawing test (CDT), a quick and easy cognitive screening test, is associated with adverse health outcomes independently of the physical phenotype of frailty. METHODS: This was a prospective population-based cohort study of 766 dementia-free Italian community dwellers aged 65 years or older. Baseline assessment included the physical phenotype of frailty, 3 different CDT protocols [Sunderland, Shulman, and the clock drawing interpretation scale (CDIS)], and several health confounders. Hazard ratios (HR) and odds ratio (OR) along with their corresponding 95% confidence intervals (CI) from models adjusted for frailty and sociodemographic and health confounders were used to estimate the independent association of the CDT with the 7-year risk of all-cause mortality and the 3-year risk of new and worsening disability, hospitalization, and fractures. RESULTS: After adjustment for confounders, the Sunderland CDT was significantly associated with all-cause mortality independently of the physical phenotype of frailty (HR = 1.44, 95% CI 1.03-2.01, p = 0.031). However, compared to all nonfrail participants with a normal Sunderland CDT, the HR was 1.57 (95% CI 1.09-2.26, p = 0.016) for those with impairment on the Sunderland CDT only, 2.48 (95% CI 1.46-4.20, p = 0.001) for those with frailty only, and 2.52 (95% CI 1.34-4.77, p = 0.004) for those with both frailty and impairment on the Sunderland CDT. Mortality was unrelated to the CDIS CDT (p = 0.359) and the Shulman CDT (p = 0.281). No statistically significant relationship was found between nonlethal outcomes and any CDT protocol, although trends were found for an association of both the Sunderland CDT (p = 0.118) and the CDIS CDT with worsening disability (p = 0.154). CONCLUSIONS: In older persons, depending on the scoring system, the CDT may predict the mortality risk independently of the physical phenotype of frailty. However, combining the two measurements does not improve their individual prognostic abilities.

Predicting hemorrhagic transformation and its timing from maximum cerebral lesion diameter in nonlacunar ischemic strokes.

OBJECTIVES: We performed this retrospective cohort study to establish which factors are mostly indicative of the appearance of hemorrhagic transformation (HT) and of its time course in a sample of nonlacunar ischemic strokes. MATERIALS AND METHODS: In 402 patients with nonlacunar ischemic stroke (75.0 ± 12.7 years, 192 male), clinical, laboratory, and neuroimaging variables obtained during the first 3 days of hospitalization were compared between patients with and without HT at computer tomography scan. RESULTS: HT was documented in 129 patients (32.1%), including 36 with parenchymal hematoma (PH), after a median time of 6 days (range 1-27). Many variables were univariately associated with HT, but only 5 of them were confirmed in Cox regression (Hazard Ratio, 95% Confidence Interval): maximum cerebral lesion diameter (CLD) in cm (1.12, 1.06-1.18; p = .0001), hemoglobin in g/dl (1.16, 1.06-1.27; p = .002), blood glucose in mmol/L (1.10, 1.03-1.18; p = .007), prior anticoagulant therapy (1.82, 1.10-3.03; p = .02), and edema with mass effect (1.72, 1.08-2.75; p = .02). Thus, the most significant predictor was CLD. The overall risk of HT was minimum for CLD < 2 cm (1.5%), intermediate for CLD ≥ 2 and < 5 cm (22%), and maximum for CLD ≥ 5 cm (58%). The residual probability of having HT decreased progressively over time, and a simple formula is proposed to predict, from CLD in cm, when the probability of HT falls below 10%. CONCLUSIONS: The main determinant of HT was CLD, a simple quantitative parameter that could prove useful, in particular, in deciding the timing of anticoagulation in cardioembolic stroke patients.

Independent predictors of ischemic stroke in the elderly: prospective data from a stroke unit.

OBJECTIVE: Incidence of ischemic stroke (IS) increases with age. Knowledge of factors associated with IS acute outcomes in the oldest-old (≥80 years) is needed to improve quality of care and resource allocation in this age group. METHODS: Data are for 769 consecutive IS patients aged ≥60 years (436 aged ≥80 years) admitted to an Italian stroke unit in a 4-year period. Demographics, prestroke disability (modified Rankin Scale ≥3) and comorbidities, IS etiology and subtype, NIH Stroke Scale (NIHSS) score, clinical and laboratory admission parameters, and medical complications were prospectively registered. Independent predictors of in-hospital death, incident disability, length of stay, discharge without rehabilitation, and no direct discharge home were identified by multiple logistic regression. Risk profiles before and after age 80 were compared. RESULTS: Poor outcomes were more frequent in the oldest-old compared to the younger patients. NIHSS score, clinical parameters of IS severity (need for oxygen, indwelling catheter, or nasogastric tube), incident disability, and medical complications predicted most of the study outcomes in both age groups. After age 80, IS etiology and subtype proved additional independent determinants for most outcomes along with age, sex, and prestroke functional and health status. CONCLUSIONS: Characteristics related to neurologic impairment on admission were the main predictors of acute outcomes of IS in this cohort. Specific IS etiology and subtype influenced IS outcomes only after age 80. In oldest-old patients, demographics and prestroke functional and health status also influenced IS outcomes with peculiar associations.