Thrombolysis treatment protected impairment of functional ability, quality of life and fatigue seven years after stroke.

OBJECTIVES: We studied quality of life, functional outcome, depression, and fatigue of ischemic stroke patients treated with or without thrombolysis seven years post-stroke. MATERIALS AND METHODS: A total of 204 ischemic stroke patients treated with or without thrombolysis during 2013-2015. After seven years the 136 survivors were assessed with telephone interview, which included questions about subjective quality of life (European Quality of Life-5 Dimensions), depression, fatigue with Fatigue Severity Scale, functional ability assessed with Barthel Index and Modified Rankin Scale, living conditions, need of care, and medical aids. RESULTS: At admission patients with thrombolysis had higher National Institutes of Health Stroke Scale scores compared with those not treated with thrombolysis. At seven years post-stroke, 99% of alive patients answered the questionnaires. There were no group differences concerning functional outcome, quality of life, depression, fatigue, or insomnia. The Barthel Index was normal in both groups. The quality of life was good in both groups without group differences in any domains. Of all patients, 68% reported no problems in usual activities, and 61% were without pain. Anxiety or depression were experienced by 19% of all stroke patients, while fatigue was present in 32% of cases. CONCLUSIONS: Seven years post-stroke the quality of life was good and functional outcome remained in good level in both study groups. One third experienced fatigue, while every fifth experienced depression. The thrombolysis treatment seems to protect from decreased quality of life, fatigue, and decreased mobility, self-care, and usual activities despite more severe stroke.

Obesity and the Risk of Cryptogenic Ischemic Stroke in Young Adults.

OBJECTIVES: We examined the association between obesity and early-onset cryptogenic ischemic stroke (CIS) and whether fat distribution or sex altered this association. MATERIALS AND METHODS: This prospective, multi-center, case-control study included 345 patients, aged 18-49 years, with first-ever, acute CIS. The control group included 345 age- and sex-matched stroke-free individuals. We measured height, weight, waist circumference, and hip circumference. Obesity metrics analyzed included body mass index (BMI), waist-to-hip ratio (WHR), waist-to-stature ratio (WSR), and a body shape index (ABSI). Models were adjusted for age, level of education, vascular risk factors, and migraine with aura. RESULTS: After adjusting for demographics, vascular risk factors, and migraine with aura, the highest tertile of WHR was associated with CIS (OR for highest versus lowest WHR tertile 2.81, 95%CI 1.43-5.51; P=0.003). In sex-specific analyses, WHR tertiles were not associated with CIS. However, using WHO WHR cutoff values (>0.85 for women, >0.90 for men), abdominally obese women were at increased risk of CIS (OR 2.09, 95%CI 1.02-4.27; P=0.045). After adjusting for confounders, WC, BMI, WSR, or ABSI were not associated with CIS. CONCLUSIONS: Abdominal obesity measured with WHR was an independent risk factor for CIS in young adults after rigorous adjustment for concomitant risk factors.

Stroke Volume Predicts Nocturnal Hypoxemia in the Acute Ischemic Stroke after Intravenous Thrombolysis.

The Goal: The aim of the study was to investigate whether stroke volume or the presence of ischemic stroke lesion on follow-up computed tomography 1 day after admission had association with sleep apnea among ischemic stroke patients undergoing thrombolysis. MATERIALS AND METHODS: We prospectively recruited 110 consecutive ischemic stroke patients and performed computed tomography on admission and after 24 hours after intravenous thrombolysis. Stroke volume was measured from post-thrombolysis computed tomography scans. Unattended cardiorespiratory polygraphy with a 3-channel device was performed during 48 hours after admission. FINDINGS: Of 110 ischemic stroke patients treated with thrombolysis 65.5% were men. Mean age was 65.8 years and body mass index 27.5 kg/m2. The mean Epworth sleepiness scale score was 4.7. Eight patients (12.7%) with visible acute stroke after thrombolysis and none in the other group had hemorrhage as complication (P ˂ .001). Sleep apnea, determined as a respiratory event index greater than or equal to 5/hour, was diagnosed in 96.4% patients. Respiratory event index greater than 15/h was found in 72.8% of patients. Both mean baseline oxygen desaturation index (23.9 versus 16.5, P = .028) and obstructive apneas/hour (6.2 versus 2.7, P = .007) were higher in visible stroke group. Stroke volume (mean 15.9 mL) correlated with proportion of time spent below saturation less than 90%, P = .025. CONCLUSIONS: Acute ischemic stroke patients treated with thrombolysis with visible stroke were more likely to have nocturnal hypoxemia than patients with not visible strokes. Stroke volume correlated with time spent below saturation of 90%.

Nocturnal hypoxemia and central apneas increase mortality, but not recurrent ischemic events after ischemic stroke.

BACKGROUND: The aim of the study was to investigate whether findings in cardiorespiratory polygraphy had an association with stroke mortality or ischemic event recurrence after ischemic stroke. METHODS: We prospectively studied 204 ischemic stroke patients who underwent cardiorespiratory polygraphy within the first 48 h after the symptom onset. We followed all these patients for a median of 6.2 years. We evaluated mortality, time of survival, causes of death and new ischemic events. RESULTS: Of 204 ischemic stroke patients, 43 died and 48 had a new ischemic event during the follow-up. The lowest arterial oxyhemoglobin saturation (min SaO2) (P = 0.007) was lower, the percentage of time spent below arterial oxyhemoglobin saturation less than 90% (T90) (P = 0.005) was higher, and central apnea index per hour (CAI/h) (P = 0.04) was higher among the deceased. Male gender, older age, diabetes mellitus, elevated modified Rankin scale (mRS) score, lower Glasgow Coma Scale (GCS) score and CAI/h independently predicted higher mortality. Peripheral arterial disease (PAD) and higher National Institutes of Health Stroke Scale (NIHSS) score were independent predictors for a recurrent ischemic event. Among those having respiratory event index (REI) at least 30, older age and lower GCS score independently predicted higher mortality. Only 21 stroke patients initiated continuous positive airway pressure (CPAP) treatment; of those, only one had a new ischemic event. CONCLUSIONS: The non-survivors had more severe nocturnal hypoxemia and more central apneas than survivors. Among patients with REI at least 30/h, increased CAI predicted higher mortality, but not independently. CLINICAL TRIAL REGISTRATION: URL:http://www. CLINICALTRIALS: gov. Unique identifier: NCT01861275.

Unattended sleep study in screening for sleep apnea in the acute phase of ischemic stroke.

OBJECTIVES: We aimed to compare the feasibility of automatically and manually scored cardiorespiratory polygraphy results for sleep apnea screening in the acute phase of ischemic stroke. METHODS: Prospective study included 204 ischemic stroke patients, who underwent nocturnal unattended portable monitoring with three-channel device during 48 h after onset of stroke symptoms. Sleep apnea diagnosis was determined as a respiratory event index (REI) ≥5/hour. RESULTS: The mean age of the patients was 67.7 years and 62.7% were males. Automatic scoring identified sleep apnea in 148/72.5% and manual scoring in 186/91.2% of patients, showing moderate agreement (Kappa value 0.407). Of the cohort, 39 (19.1%) patients fulfilled the criteria for diagnosis of central sleep apnea (CSA) (>50% of events central) and 165 (80.9%) had obstructive sleep apnea (OSA). Automatic scoring identified poorly the type of events, and missed 18.6% of recordings. Oxygen desaturation 4% index (ODI4), interclass correlation coefficient (ICC) value 0.993, (95% CI 0.990-0.994), lowest saturation (ICC value 0.989, 95% CI 0.985-0.991) and percent of time spent <90% (ICC value 0.987, 95% CI 0.982-0.990) showed excellent agreement. Interclass correlation value for REI was 0.869 (95% CI 0.828 to 0.901) and ICC value 0.848 (95% CI 0.800 to 0.885) for obstructive apnea index, both indicating good agreement. Automatic scoring underestimated the severity of sleep apnea. CONCLUSIONS: Both automatically and manually scored results recognized sleep apnea, albeit manual scoring identified more sleep apnea. Sleep apnea diagnosis agreement was moderate. Underestimation of the severity of sleep apnea by automatic scoring may result in undertreatment of sleep apnea. CLINICAL TRIAL REGISTRATION: URL:http://www.clinicaltrials.cov. Unique identifier: NCT01861275.

The Evolution of Sleep Apnea Six Months After Acute Ischemic Stroke and Thrombolysis.

STUDY OBJECTIVES: Our goal was to investigate the evolution of prevalence, severity, and type of sleep apnea among patients who had an ischemic stroke, with or without treatment with thrombolysis after 6 months. METHODS: We prospectively studied 204 patients who had an ischemic stroke (110 in the thrombolysis and 94 in the non-thrombolysis group). After follow-up, 177 patients were eligible for a final analysis (98 in the thrombolysis group and 79 in the non-thrombolysis group). An unattended sleep study with a three-channel portable device was performed both on admission and after the 6-month follow-up. RESULTS: The patients receiving thrombolysis were younger than those in the non-thrombolysis group (mean 65.5 versus 69.6 years P = .039). Sleep apnea, defined as a respiratory event index (REI) ≥ 5 events/h, was diagnosed in 92.7% patients, 93.9% versus 91.1% (P = .488) in the thrombolysis and non-thrombolysis groups, respectively. The prevalence remained unchanged during follow-up. Mild sleep apnea progressed to moderate or severe sleep apnea in 69.2% of the patients. Globally, mean central apneas per hour increased by 2.2% (P = .002), whereas obstructive apneas declined by 1.7% (P = .014). The mean change of oxygen desaturation index was -6.1% (P < .001) in the thrombolysis group, -1.8% (P = .327) in the non-thrombolysis group, and 4.2% (P = .001) in the whole group. In the non-thrombolysis group, the risk for new sleep apnea incidence increased by 6.1-fold (P = .024) at follow-up when compared to the thrombolysis group. CONCLUSIONS: Sleep apnea prevalence remained high in patients who had an ischemic stroke at 6 months post-stroke. The risk for developing sleep apnea after stroke was significantly lower among patients undergoing thrombolysis. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Title: Ischaemic Stroke and Sleep Apnea in Northern Part of Finland; Identifier: NCT01861275; URL: https://clinicaltrials.gov/ct2/show/NCT01861275.

Prevalence of sleep apnea at the acute phase of ischemic stroke with or without thrombolysis.

OBJECTIVE: The aim of the study was to compare the prevalence, type, and severity of sleep apnea during the acute phase of ischemic stroke among patients either receiving or not receiving thrombolysis. METHODS: We recruited 246 consecutive adult ischemic stroke patients. Patients underwent cardiorespiratory sleep study with portable three-channel device during the first 48 h after the symptom onset of ischemic stroke. RESULTS: We enrolled 110 (65.5% male) stroke patients in the thrombolysis group and 94 (59.6% male) in the nonthrombolysis group. In the thrombolysis group, the median National Institutes of Health Stroke Scale (NIHSS) score was higher (5.5) compared to the nonthrombolysis group (2.0) (p < 0.001). There was a lower incidence of lacunar (17.3% vs 36.2%, p = 0.002) and cerebellar (2.7% vs 16.0%, p < 0.001) strokes and a higher frequency of middle cerebral artery syndrome (60.9% vs 33.0%, p < 0.001) in the thrombolysis group compared to the nonthrombolysis group. Sleep apnea defined as an apnea-hypopnea index (AHI) ≥ 5/h was diagnosed in 186 (91.2%) patients, its prevalence being higher in the thrombolysis (96.4%) compared to the nonthrombolysis (85.1%) group (p = 0.007). The mean baseline AHI was 33.7/h in the thrombolysis group compared to 26.8/h in the nonthrombolysis group (p = 0.017). CONCLUSION: Sleep apnea was present in the vast majority of ischemic stroke patients. The stroke patients treated with thrombolysis were more likely to have sleep apnea, to have elevated NIHSS score at admission, and to be younger. Sleep apnea was more severe among those receiving thrombolysis as compared to those who were not. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.cov. Unique identifier: NCT01861275.