Analysis of the Association Between Polymorphisms within PAI-1 and ACE genes and Ischemic Stroke Outcome After rt-PA Therapy.

PURPOSE: Treatment of Ischemic stroke (IS) in acute phase is based on the use of thrombolytic rt-PA therapy. We aimed to determine whether different alleles and genotypes of I/D ACE gene and 4G/5G PAI-1 gene polymorphisms may influence outcome of rt-PA therapy in patients with IS and the occurrence of haemorrhagic transformation (HT). METHODS: Our study included 94 consecutive patients with IS treated with rt-PA. Modified Rankin Scale (mRS) at 3rd month after IS was used to determine the stroke outcome, with scores 0-1 defining the favourable outcome, and scores 2-6 defining poor outcome. Genotypisation of the ACE-1 I/D polymorphism was performed by polymerase chain reaction and of the PAI-1 4G/5G polymorphism by polymerase chain reaction - restriction fragment length analysis. RESULTS: Regarding PAI-I 4G/5G polymorphism, 44 patients (46.8%) were heterozygotes, and the number of 4G/4G and 5G/5G homozygotes was the same - 25 each (26.6%). Number of heterozygotes for the ACE I/D polymorphism was 54 (57.4%), 9 patients (9.6%) had II, and 31 (33%) DD genotypes. A favourable outcome was recorded in 26 (28.0%) and the poor outcome in 67 (72.0%) patients. Favourable and poor outcome groups did not differ significantly in PAI-1 4G/5G and ACE I/D polymorphisms genotype or allele frequencies. There was a statistically significant difference in the occurrence of HT between patients with ACE II and patients with ACE ID or DD genotypes (p=0.035). CONCLUSION: Results of our study suggest that stroke patients with ACE II genotype, treated with rt-PA, may be at risk of HT.

Diabetes mellitus may affect short-term outcome of Guillain-Barré syndrome.

We sought to determine influence of diabetes mellitus on Guillain-Barré syndrome (GBS) course and short-term prognosis. Among the 257 GBS patients included in this retrospective study, diabetes mellitus was present in 17%. The degree of disability at admission and on discharge was assessed according to the GBS Disability Scale (mild disability = 0-3, severe disability = 4-6). Even after correction for age, diabetes mellitus was significantly associated with more severe disability at nadir (odds ratio, OR = 3.4, p < 0.05) and on discharge (OR = 2.0, p < 0.05). Linear regression analysis with multiple factors included showed that age and presence of diabetes were significant predictors of severe disability at nadir (adjusted R2 = 0.21, p < 0.05), and on discharge (adjusted R2 = 0.19, p < 0.05). The presence of diabetes mellitus affects short-term prognosis of GBS, independent of age.

Long-Term Prognosis in Ischemic Stroke Patients Treated with Intravenous Thrombolytic Therapy.

BACKGROUND AND PURPOSE: It remains unclear if intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator has an impact on the survival and maintenance of a favorable effect on functional recovery over a long follow-up period. The aim of this study was to assess whether or not IVT treatment has a favorable effect on functional recovery and survival less than 1 year after a stroke. METHODS: This matched cohort study included 259 patients with acute ischemic stroke (IS) who were treated with IVT and standard care and 259 patients treated with standard care alone in the stroke unit between February 2006 and January 2013. RESULTS: After a median follow-up period of 3 years (range, 1-7 years), survival did not differ significantly between the groups; specifically, 56 patients (21.6%) in the thrombolysed group died versus 62 patients (23.94%) in the nonthrombolysed group (log-rank, .240, P = .624). Based on a multivariate Cox proportional hazards regression model, older age (>70 years), stroke severity (National Institutes of Health Stroke Scale score ≥ 15), diabetes mellitus, and a history of atrial fibrillation were independent predictors of long-term mortality after stroke. After the follow-up period, 144 patients (55.6%) in the IVT-treated group versus 112 patients (43.2%) in the control group had an excellent outcome, with a modified Rankin Scale score of 0-1 (hazard ratio [HR] = 1.64, 95% confidence interval [CI] = 1.16-2.32). Based on a multivariate Cox proportional hazards regression model, an excellent 3-month functional recovery was a strong predictor of favorable outcome (HR = 11.27, 95% CI = 6.45-19.63). CONCLUSION: The results suggest that IVT for acute IS has a favorable effect on functional recovery more than 1 year after stroke.

How to recognize and treat metabolic encephalopathy in Neurology intensive care unit.

Metabolic encephalopathy (ME) represents a syndrome of temporary or permanent disturbance of brain functions that occurs in different diseases and varies in clinical presentation. It can be manifested in a range from very mild mental disorders to deep coma and death. Clinically, it is characterized by a variety of psychiatric and neurological symptoms and signs. The most common causes of ME are: hypoxia, ischemia, systemic diseases and toxic agents. ME is the most frequent in elderly people who have previously been exhausted by chronic illnesses and prolonged stay in bed. ME is a very common complication in patients treated in intensive care units. Treatment and prognosis of the disease are varied and depend on aetiology, as well as on the type and severity of clinical presentation. Mortality of patients with septic encephalopathy ranges from 16-65%, while the one-year survival of patients with encephalopathy and liver cirrhosis is less than 50%.

Return to Paid Work after Ischemic Stroke in Patients Treated with Intravenous Thrombolysis.

BACKGROUND: There are no available data confirming the efficacy of intravenous thrombolytic (IVT) treatment on the return to work as one of important outcome measure after acute ischemic stroke (IS). The aim of this study was to analyze the influence of IVT treatment on the return to work after stroke. METHODS: This matched cohort study included 279 patients with acute IS (146 treated with IVT and 133 matched patients without IVT) admitted to the Stroke Unit between 2007 and 2013. All patients were working in paid employment immediately before stroke onset. The main outcome measure was return to full-time paid work during follow-up period. RESULTS: After a median follow-up period of 3 years (range 1-7 years), the prevalence of stroke survivors returning to paid work was 42.1% in the IVT group and 33.3% in the non-IVT group (hazard ratio 1.28, 95% CI 0.86-1.91), and IVT treatment was associated with a higher chance of returning to full-time jobs (OR 2.07, 95% CI 1.21-3.51). After adjustment for possible variables, IVT was an independent predictor of returning to full-time jobs. CONCLUSION: IVT treatment was a positive predictor of returning to full-time work after stroke.

Guillain-Barré syndrome in the elderly.

The aim of the study was to analyze specific features of Guillain-Barré syndrome (GBS) in old people. The study included 403 GBS patients (62% young [<60 years], 35% young-old [60-80 years], and 3% old-old [>80 years]). Diagnosis of GBS was made according to the National Institute of Neurological Disorders and Stroke (NINDS criteria). Severe disability (GBS disability score of >3) at nadir was more common in old compared with young patients (p = 0.0001) as was mortality (9% vs. 2%, respectively). Acute motor and sensory axonal neuropathy and hyponatremia were more common in old compared with young patients (12% vs. 6% and 27% vs. 18%, respectively, p = 0.04). A positive history for malignancy was more than three times more common in old than young patients (11% vs. 3%, respectively, p = 0.01). Disability on nadir was similar in young-old and old-old subjects with disability on discharge being more severe in old-old (p = 0.04) suggesting slower recovery in this subgroup. Bulbar symptoms were more common in old-old compared with young-old (50% vs. 19%, respectively, p = 0.01). Comorbidities were present in virtually all old-old patients compared with 66% of young-old patients (p = 0.04). In conclusion, Elderly patients, and especially old-old patients, with GBS have more severe disease with slower recovery than do younger patients.

Clinical and epidemiological features of Guillain-Barré syndrome in the Western Balkans.

The aim of this study was to define features of Guillain-Barré syndrome in a large cohort of patients from three Western Balkans countries. Data from adult Guillain-Barré syndrome (GBS) cases from 2009 to 2013 were retrospectively obtained from all tertiary health care centers. During the 5-year period, 327 new cases of GBS were identified with a male to female ratio of 1.7 : 1. The most common GBS variants were demyelinating (65%) and axonal (12%). At nadir 45% of patients were chair-bound, confined to bed, or required assisted ventilation, while 5% died. The crude incidence of GBS in Serbia and Montenegro was 0.93 per 100,000 population, and age-adjusted incidence according to the world standard population was 0.86 per 100,000. Incidence was particularly high in 50- to 80-year-old men. Statistically significant seasonal variations of GBS were not observed. This study of patients with GBS in the Western Balkans allows us to prepare the health system better and to improve the management of patients. This study also opens opportunities for international collaboration and for taking part in the multinational studies on GBS.

Effect of intravenous thrombolysis on stroke associated with atrial fibrillation.

BACKGROUND: Data based on randomized clinical trials regarding the efficacy and safety of intravenous thrombolysis (IVT) versus placebo or any other antithrombotic agent in the treatment of stroke associated with atrial fibrillation (AF) are unavailable. METHODS: Prospectively collected data on AF-associated stroke patients treated in a 3-year period were analyzed to assess the effect of IVT treatment. Outcome measures were modified Rankin Scale (mRS) score for functional outcome, death, and symptomatic intracerebral hemorrhage (sICH). RESULTS: Of 787 patients diagnosed with an acute ischemic stroke in the observed period, 131 (16.6%) had AF. Multivariate logistic regression analysis after adjustment for confounders demonstrated that independent predictors of excellent outcome (mRS 0-1) in patients with AF-associated stroke were lower baseline National Institutes of Health Stroke Scale [NIHSS] score (adjusted odds ratio [(adj)OR], .87; 95% confidence interval [CI], 0.81-.94; P = .000) and the use of IVT ((adj)OR, 5.31; 95% CI, 1.90-14.82; P = .001), whereas independent predictors of death were higher baseline NIHSS score ((adj)OR, 1.07; 95% CI, 1.02-1.12; P = .003), previous stroke ((adj)OR, 4.11; 95% CI, 1.49-11.35; P = .006), absence of IVT use ((adj)OR, .19; 95% CI, .05-.77; P = .021), sICH ((adj)OR, 18.52; 95% CI, 1.59-215.37; P = .020), and higher serum glucose levels ((adj)OR, 1.26; 95% CI, 1.06-1.50; P = .008). Thrombolyzed patients with AF were less severe at baseline and were less likely to have NIHSS >18. They were more likely to have excellent and good functional outcome (mRS 0-2) whereas less likely to have death as outcome at 3 months. Thrombolyzed AF patients had constantly lower probability of death regardless of the baseline NIHSS score values. CONCLUSIONS: These results should encourage the use of IVT in AF-associated strokes.

Safety of thrombolysis in stroke mimics: results from a multicenter cohort study.

BACKGROUND AND PURPOSE: Intravenous thrombolysis for acute ischemic stroke is beneficial within 4.5 hours of symptom onset, but the effect rapidly decreases over time, necessitating quick diagnostic in-hospital work-up. Initial time strain occasionally results in treatment of patients with an alternate diagnosis (stroke mimics). We investigated whether intravenous thrombolysis is safe in these patients. METHODS: In this multicenter observational cohort study containing 5581 consecutive patients treated with intravenous thrombolysis, we determined the frequency and the clinical characteristics of stroke mimics. For safety, we compared the symptomatic intracranial hemorrhage (European Cooperative Acute Stroke Study II [ECASS-II] definition) rate of stroke mimics with ischemic strokes. RESULTS: One hundred stroke mimics were identified, resulting in a frequency of 1.8% (95% confidence interval, 1.5-2.2). Patients with a stroke mimic were younger, more often female, and had fewer risk factors except smoking and previous stroke or transient ischemic attack. The symptomatic intracranial hemorrhage rate in stroke mimics was 1.0% (95% confidence interval, 0.0-5.0) compared with 7.9% (95% confidence interval, 7.2-8.7) in ischemic strokes. CONCLUSIONS: In experienced stroke centers, among patients treated with intravenous thrombolysis, only a few had a final diagnosis other than stroke. The complication rate in these stroke mimics was low.

Predicting the outcomes of acute ischaemic stroke in atrial fibrillation: the role of baseline CHADS2, CHA2DS2-VASC and HAS-BLED score values.

OBJECTIVE: Atrial fibrillation (AF)-related risk of stroke is commonly assessed using the CHADS2 or CHA2DS2-VASc score, whilst the oral anticoagulation-related bleeding risk can be estimated by the HAS-BLED score. We investigated the association of these scores with outcomes of AF-associated strokes, defined as symptomatic intracranial haemorrhage (sICH), favourable outcome (modified Rankin Scale [mRS] 0-2) or death. METHODS: Analyses of prospective data on stroke patients with non-valvular AF treated in the Stroke Unit from January 2009 to June 2012 were performed. RESULTS: Of 787 patients with an acute ischaemic stroke, 131 had AF (16.6%, median age 70, range 62-76 years). Of those, 6 patients (4.6%) had sICH, 49 (37.4%) died and 55 (42.0%) had a favourable 90-day outcome. HAS-BLED score of > or = 3 was associated with sICH both in the univariate analysis (OR 15.13; 95% CI 2.11-108.25, P = 0.007) and in the multivariable model (OR 19.96; 95% CI 2.23-178.81, P = 0.007), which also included the baseline neurological deficit score (NIHSS), intravenous thrombolysis or the use of antiplatelet/anticoagulant therapy. The CHADS2 and CHA2DS2-VASc scores were associated with 90-day mortality in the univariate analyses (OR 1.47; 95% CI 1.11-1.95 and OR 1.36; 95% CI 1.08-1.69, respectively, both P = 0.008). The CHA2DS2-VASc score was inversely related to the favourable outcome in the univariate analysis (OR 0.80; 95% CI 0.65-0.99, P = 0.042). CONCLUSION: HAS-BLED was found to have an independent predictive value on the occurrence of sICH regardless of the treatment (thrombolysis or conservative therapy). A trend toward statistical relation to the influence of the CHA2DS2-VASc values on the favourable outcome was registered.

The frequency of poststroke infections and their impact on early stroke outcome.

INTRODUCTION: Poststroke infections are the most common medical complications of stroke and can occur in up to 65% of patients. The aim of this study was to assess the rate of infectious complications during hospitalization of stroke patients and to evaluate the impact of infection in general, including each of the urinary tract infection (UTI), pneumonia, and sepsis, on fatal and poor functional outcome at discharge. METHODS: This retrospective study enrolled patients who have been diagnosed with acute ischemic stroke treated in a 1-year period. Poor functional outcome at discharge was defined as severe invalidity and included patients with modified Rankin Scale score of 3-5. Univariate and multivariate analyses were performed. RESULTS: We analyzed 133 patients with acute ischemic stroke. Poststroke infection occurred in 63 (47.4%) patients. The most common infection was UTI that was present in 27 (20.3%) patients. Multivariate logistic regression analysis after adjustment for confounders demonstrated that poststroke infection was an independent predictor of poor functional outcome (odds ratio [OR] 12.82, 95% confidence interval [CI] 4.09-40.0, P < .001) and death at discharge (OR 14.92, 95% CI 2.97-76.92, P = .001). When analyzing the impact of each infectious complication, multivariate logistic regression showed that UTIs were an independent predictor of poor functional outcome (OR 14.08, 95% CI 3.06-64.84, P = .001) and death (OR 9.81, 95% CI 1.46-65.68, P = .019) at discharge. CONCLUSION: Infection is a frequent poststroke complication and represents an independent predictor of poor functional and fatal early stroke outcome.

Influence of differences in case mix on the better outcome of smokers after intravenous thrombolysis for acute cerebral ischemia.

BACKGROUND/AIMS: Thrombolysis for myocardial infarction is more effective in smokers. Our aim was to determine whether smokers treated by intravenous (i.v.) rt-PA for acute cerebral ischemia have better outcomes. METHOD: Comparison of smokers and non-smokers for baseline characteristics and month-3 outcome in patients treated by i.v. rt-PA for cerebral ischemia in Lille, France, and Belgrade, Serbia. The primary outcome was a modified Rankin scale (mRS) 0-1 or similar to the pre-stroke mRS. Secondary outcomes were an mRS 0-2 and death. RESULTS: We included 459 patients (255 men; median age 65 years, interquartile range 52-76; 135 smokers). Smokers were younger (median 53 vs. 70 years, p < 0.0001) and had less severe strokes (median NIHSS 10 vs. 14, p < 0.0001). At month 3, they were more likely to have an mRS 0-1 [odds ratio (OR) 1.75; 95% confidence interval (CI) 1.17-2.62], or an mRS 0-2 (OR 2.90; 95% CI 1.86-4.52) and less likely to be dead (OR 0.28; 95% CI 0.13-0.61). Smoking was not independently associated with outcome after adjustment for case mix [adjusted OR ((adj)OR) 0.86; 95% CI 0.52-1.43]. CONCLUSION: Smoking does not independently influence the outcome in patients treated by rt-PA for cerebral ischemia. The better outcome in smokers is the consequence of differences in case mix.

Intravenous thrombolysis for acute cerebral ischemia in Belgrade, Serbia: comparison with Lille, France.

BACKGROUND: Worse socioeconomic situation is associated with worse outcomes in stroke cases. Whether it also influences outcomes in patients treated with intravenous thrombolysis remains unknown. The aim of this study was to test the hypothesis that outcomes are less favorable in patients treated with intravenous thrombolysis in Belgrade, Serbia, than in Lille, France. METHODS: We compared outcomes at day 7 and month 3, between 123 consecutive stroke patients treated with intravenous thrombolysis in Belgrade and 273 in Lille. RESULTS: At month 3, there was no significant difference between Belgrade and Lille in patients' excellent outcomes [modified Rankin Scale 0-1; 49.6 vs. 45.4%, odds ratio (OR): 1.21, 95% confidence interval (CI): 0.79-1.86] or in death (11.4 vs. 16.1%, OR 0.67, 95% CI: 0.35-1.27). However, compared with a subgroup of age-matched patients from Lille, Belgrade patients tended to have worse outcomes. Patients from Belgrade were 16 years younger (p < 0.0001), more likely to be men (OR 2.40, 95% CI: 1.52-3.78), and more likely to be smokers (OR 2.24, 95% CI: 1.43-3.51). Also, a trend for a slightly higher rate of symptomatic hemorrhagic transformation was registered in this group (7.3 vs. 3.3%, OR 2.32, 95% CI: 0.90-5.99). In Belgrade, patients arrived 27 min earlier to the hospital (p < 0.0001), but their door-to-needle time was 37 min longer (p < 0.0001). Compared with a subgroup of age-matched patients from Lille, they tended to have worse outcomes. CONCLUSION: Intravenous thrombolysis-treated stroke patients in Belgrade have similar outcomes and rates of complications as those from Lille.

TT genotype of the MMP-9-1562C/T polymorphism may be a risk factor for thrombolytic therapy-induced hemorrhagic complications after acute ischemic stroke.

INTRODUCTION: Levels of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) influence recombinant tissue plasminogen activator (rtPA) therapy response in patients with acute ischemic stroke (AIS). Serum levels of MMPs and TIMPs along with the expression of genes coding these proteins are related to the recovery and appearance of adverse effects (AE) after AIS. Consequently, it is important to explore whether polymorphisms in regulatory sequences of MMPs and TIMPs are associated with rtPA response in AIS patients. OBJECTIVES: To determine whether selected polymorphic variants within MMP-2, MMP-9, and TIMP-2 genes may influence rtPA therapy response with regard to outcomes in patients with AIS and the occurrence of AE. METHODS: Our study included 166 patients suffering AIS, treated with rtPA. Patients' recovery was estimated using the Modified Rankin Scale (mRS) 3 months after the AIS occurred. Favorable outcome was defined with scores 0-1 and poor outcome with scores 2-6. Genotyping was performed using real-time PCR (rs243866, rs243865, rs243864, rs2277698, and rs8179090) and PCR-RFLP (rs2285053, rs3918242) methods. Additionally, rtPA AE were followed during the hospitalization. RESULTS: There was no significant association between genotypes and alleles of selected polymorphisms and rtPA therapy response measured through the decrease of the mRS score in patients with AIS. Intracranial hemorrhage, as well as parenchymal hematoma type 2, was significantly more frequent in patients with TT genotype of the MMP-9-1562C/T polymorphism (p = 0.047, p = 0.011, respectively). Patients with intracranial hemorrhages after rtPA were significantly more likely to have the TT genotype of TIMP-2-303C/T polymorphism and the TT genotype of MMP-9-1562C/T polymorphism (p < 0.001). CONCLUSION: TT genotype of the MMP-9-1562C/T polymorphism may be a risk factor for rtPA-induced hemorrhagic complications after AIS.

Long-term medication persistence in stroke patients treated with intravenous thrombolysis.

OBJECTIVE: There are no data regarding long-term medication persistence in stroke survivors treated with intravenous thrombolysis (IVT), which is one of the most important determinants of treatment success. Our objective was to determine long-term medication persistence in stroke patients treated with IVT. METHODS: This retrospective observational study included 203 IVT-treated and 197 non-IVT treated patients with acute ischemic strokes (IS) admitted to the Stroke Unit between January 2007 and January 2013. RESULTS: During a median follow-up period of 3 years (range 1-7 years), 56 (21.6%) patients in the IVT-group and 62 (23.9%) patients in the non-IVT-group died. There was a higher medication persistence for all secondary stroke prevention medications (anti-thrombotic agents, anti-hypertensive drugs, statins and hypoglycemic drugs) in the IVT-group compared to the non-IVT group (88.7% vs. 69.0%; OR=3.68, 95% CI=2.17-6.23). After adjusting for baseline characteristics and possible confounders IVT was the independent predictor of medication persistence (OR=2.93, 95% CI=1.48-5.81, p=0.002). Higher medication persistence was observed in patients with favorable long-term functional outcome, both in the IVT-group (OR=4.37, 95% CI=1.83-10.40, p<0.001) and the non-IVT-group (OR=3.46, 95% CI=1.84-6.52, p<0.001). CONCLUSION: Medication persistence was higher among IVT-treated patients compared to non-IVT-treated patients. The higher rate of non- medication persistence was recorded among patients with more pronounced disabilities after stroke.

Intravenous thrombolysis in acute ischemic stroke due to occlusion of internal carotid artery - a Serbian Experience with Thrombolysis in Ischemic Stroke (SETIS).

OBJECTIVE: The benefit of intravenous thrombolysis in patients with internal carotid artery (ICA) occlusion is still unclear. The aim of this study was to assess the influence on outcome of intravenous thrombolysis in patients with ICA occlusion comparing to those without it. METHODS: Data were from the national register of all acute ischemic stroke patients treated with intravenous thrombolysis in Serbia. Patients with nonlacunar anterior circulation infarction were included and were divided into two groups, those with and those without ICA occlusion. We compared the differences in demographic characteristics, risk factors, baseline NIHSS score, early neurological improvement, 3-month functional outcome, complications and death between these two groups. RESULTS: Among 521 included patients there were 13.4% with ICA occlusion. Group with ICA occlusion had more males (82.9% vs. 60.5%; p=0.0008), and more severe stroke (baseline NIHSS score 15.3 vs. 13.6; p=0.004). Excellent functional outcome (mRS 0-1) at 3 months was recorded in 32.9% patients with ICA occlusion and in 50.6% patients without (p=0.009), while favorable functional outcome (mRS 0-2) was recorded in 50.0% of patients with ICA occlusion vs. 60.1% without (p=0.14). Death occurred in 12.9% patients with ICA occlusion and in 17.3% patients without it (p=0.40). There was no significant difference in rate of symptomatic ICH between the two groups (1.4% vs. 4.2%; p=0.5). Multivariate logistic regression analysis showed that ICA occlusion was associated with the absence of early neurological improvement (p=0.03; OR 1.78, 95% CI 1.05-3.04). However, the presence of ICA occlusion was not significantly associated with an unfavorable outcome at 3-month (p=0.44; OR 1.24, 95% CI 0.72-2.16) or with death (p=0.18; OR 0.57, 95% CI 0.25-1.29). CONCLUSION: The patients with ICA occlusion treated with intravenous thrombolysis have a worse outcome than patients without it.

Short-term and long-term stroke survival: the belgrade prognostic study.

BACKGROUND AND PURPOSE: The aims of this study were to determine the 28-day and 1-year survival rates after first-ever ischemic stroke and to identify their baseline predictors. METHODS: We prospectively and consecutively collected data on 300 patients with first-ever acute ischemic stroke admitted to 2 major neurological institutions for cerebrovascular diseases in Belgrade during March 2008. The Kaplan-Meier method was used to estimate the cumulative 28-day and 1-year survival rates, and the predictive values of different variables were assessed by Cox proportional-hazards regression model. RESULTS: The cumulative 28-day and 1-year survival rates of ischemic stroke patients in the cohort were 81.0% and 78.3%, respectively. The multivariate predictive model revealed that hypertension (p=0.017), National Institutes of Health Stroke Scale score (p=0.001), and in-hospital medical complications (p=0.029) were significant unfavorable independent outcome predictors, while early physical therapy (p=0.001) was a significant favorable prognostic factor for the 28-day mortality in our patients. Multivariate Cox regression analysis showed that age (p=0.001), National Institutes of Health Stroke Scale score (p=0.001), and in-hospital complications (p=0.008) remained significant predictors of 1-year mortality. CONCLUSIONS: The findings support the need for optimal control of vascular risk factors and treatment of atherosclerotic disease as well as appropriate prevention and management of in-hospital complications of stroke.

Outcome of patients with atrial fibrillation after intravenous thrombolysis for cerebral ischaemia.

The question of whether i.v. rt-PA is beneficial in patients with ischaemic stroke and atrial fibrillation (AF) remains unresolved. Our objective was to evaluate the outcome of patients with AF who received i.v. rt-PA for stroke in the registries of Lille (France) and Belgrade (Serbia). End-points were poor outcome [modified Rankin Scale (mRS) 3-6], and symptomatic haemorrhagic transformation (sHT) according to ECASS3. Of 734 consecutive patients, 155 (21.2 %) had AF. The unadjusted comparison found patients with AF to be 12 years older, more likely to be women, to have hypertension, and baseline INR > 1.2, and less likely to be smokers. They had higher baseline NIHSS scores, diastolic blood pressure, and serum glucose concentrations, and lower platelet counts. They did not differ for sHT (5.8 vs. 5.5 %; p = 0.893), but they more frequently had poor outcomes (52.3 vs. 35.2 %; p < 0.001) and death (21.9 vs. 9.0 %; p < 0.001). The only independent predictor of sHT was baseline NIHSS (adjOR 1.05 per 1 point increase; 95 % CI 1.01-1.10). Independent variables associated with poor outcome were age (adjOR 1.04 for 1 year increase; 95 % CI 1.03-1.06), baseline NIHSS (adjOR 1.17 per 1 point increase; 95 % CI 1.13-1.21), and sHT (adjOR 47.6; 95 % CI 10.2-250) but not AF. In patients treated with i.v. rt-PA for cerebral ischaemia, those with AF have worse outcomes because they are older and have more severe strokes at admission. This result suggests that we should focus on prevention and research of more aggressive strategies at the acute stage.

Stroke care in Central Eastern Europe: current problems and call for action.

Stroke is a major medical problem and one of the leading causes of mortality and disability all over in Europe. However, there are significant East-West differences in stroke care as well as in stroke mortality and morbidity rates. Central and Eastern European countries that formerly had centralized and socialist health care systems have serious and similar problems in organizing health and stroke care 20 years after the political transition. In Central and Eastern Europe, stroke is more frequent, the mortality rate is higher, and the victims are younger than in Western Europe. High-risk patients live in worse environmental conditions, and the socioeconomic consequences of stroke further weaken the economic development of these countries. To address these issues, a round table conference was organized. The main aim of this conference was to discuss problems to be solved related to acute and chronic stroke care in Central and Eastern European countries, and also, to exchange ideas on possible solutions. In this article, the discussed problems and possible solutions will be summarized, and introduce 'The Budapest Statement of Stroke Experts of Central and Eastern European countries'.

Intravenous thrombolysis in the treatment of ischemic stroke due to spontaneous artery dissection.

OBJECTIVES: Data based on randomized clinical trials regarding intravenous thrombolysis (IVT) versus placebo or any other antithrombotic treatment in ischemic stroke (IS) due to artery dissection (AD) are not available. METHODS: We used data from our observational study to examine the efficacy and safety of IVT in patients with IS due to spontaneous AD, as compared with stroke patients of the same cause who were not treated with IVT. Outcome measures were modified Rankin score (mRS) for functional outcome, death from all causes, occurrence of any intracranial hemorrhage, local signs of an intramural hematoma extension, recurrent IS, and recurrent AD. RESULTS: In a 4-year period, 19 of 46 patients with IS due to spontaneous AD were treated with IVT. Favorable outcome (mRS 0-2) after the follow-up period reached 81.5% of non-IVT patients compared with 94.7% of IVT-treated patients (odds ratio, 4.09; 95% confidence interval, 0.44-38.26; P=0.377). However, the patients who received IVT had a significantly higher chance of being without any neurological deficit (mRS 0) after adjusting for age, sex, baseline National Institutes of Health Stroke Scale score, and site of dissection compared with non-IVT patients after the follow-up period (P=0.012). No symptomatic intracerebral hemorrhage, worsening of local signs, cases of subarachnoid hemorrhage, or death occurred in both groups of patients. CONCLUSIONS: The efficacy of IVT in patients with IS due to the spontaneous AD seemed to be similar or even better to those of patients of the same cause who were not treated with IVT. The complication rate of IVT in spontaneous AD is low.