Combined quality of life and survival for estimation of long-term health outcome of patients with stroke.

BACKGROUND: Advanced medical technologies can prolong life of stroke survivors. Dynamic change of health outcomes provides essential information to manage stroke. Mathematical models, to extrapolate health status over a lifetime from cross-sectional data, can be used to investigate long term health outcomes among stroke survivors. This study aimed to estimate the health outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) at each survival time point. METHODS: The cohort of 5391 patients with IS and ICH stroke, registered at Ramathibodi Hospital from 2005 to 2013, were followed up regarding survival status until 2016 with the National Mortality Registry. Survival functions were extrapolated over 50 years to age- and sex-matched referents simulated from the national data of the Thailand National Health Statistic Office. From July to December 2016, the EuroQoL 5-dimension questionnaire was used to measure quality of life (QoL) among 400 consecutive, cross-sectional subsamples. The survival functions were then adjusted by the utility values of QoL for the stroke cohort to estimate quality adjusted life expectancy (QALE). RESULTS: The average health utility values were lower in the initial months, then slowly increased to stable levels. However, male stroke survivors presented higher health utility than females. Throughout lifetime estimation, patients with IS stroke exhibit better health outcomes than those with ICH [10.2 vs. 7.5 quality-adjusted life years (QALYs)]. Patients with ICH presented a significantly decreased QoL than patients with IS (16.3 and 8.5 QALYs). CONCLUSION: Preventing stroke can save people from reduced years and QoL, which can be quantified by loss-of-QALE in QALY units to compare health benefits from prevention, clinical diagnosis and direct treatment.

Atrial fibrillation and paroxysmal atrial fibrillation detection in patients with acute ischemic stroke.

BACKGROUND: Studies about continuous electrocardiographic (ECG) monitoring in detection of paroxysmal atrial fibrillation (PAF) in Asian patients with acute ischemic stroke are very limited. We looked for the prevalence and associated factors of atrial fibrillation (AF) and PAF in Thai patients with acute ischemic stroke. METHODS: In all, 204 patients with acute ischemic stroke were prospectively included. Snapshot 12-lead ECG and continuous ECG monitoring for at least the first 24 hours were performed. Multivariate analyses were performed to find out the associated factors of AF and PAF. RESULTS: AF was diagnosed in 31 patients (15%) and PAF in 15 patients (7%). Twelve and 3 patients with PAF were diagnosed by continuous ECG monitoring and snapshot 12-lead ECG, respectively. Mean duration of continuous ECG monitoring and mean time to detect PAF were 55 and 23 hours, respectively. Multivariate analysis revealed that age of 70 years or older (odds ratio [OR] 3.52, 95% confidence interval [CI] 1.68-7.35, P = .001) and heart diseases (OR 4.26, 95% CI 1.14-15.95, P = .031) were associated with AF and PAF. CONCLUSIONS: AF/PAF was one of the common causes of ischemic stroke in Thai patients. Most PAF was detected by continuous ECG monitoring. Snapshot 12-lead ECG and continuous ECG monitoring should be recommended in all patients with acute ischemic stroke.

Blood pressure control among stroke patients in Thailand--the i-STROKE study.

BACKGROUND: Direct correlation between stroke mortality and hypertension calls for a tight blood pressure (BP) control. Our study determined the prevalence of the BP control and evaluated current clinical practices on hypertension management in stroke patients in Thailand. METHODS: This multicenter, cross-sectional, retrospective, observational study was carried out between February 2010 and January 2011 and enrolled stroke patients aged 45 years or older with ictus incidence 12,030 days before the enrollment. The events were confirmed by either computerized tomography scan or magnetic resonance imaging. Patient data including demographics, medical, and clinical history were collected. RESULTS: At enrollment, 274 of 558 (49.1%) patients had controlled arterial BP with an average pressure of 134.220.4/78.812.8 mm Hg; 412 (73.8%) patients received antihypertensive medications and the most common use was angiotensin-converting enzyme inhibitors (ACEIs), reported in 200 (35.8%) patients. With questionnaire, insufficient antihypertensive use and lack of patients' awareness were the 2 most common reasons given by physicians for the patients' uncontrolled BP. Factors identified to have adverse association with the controlled BP at enrollment were diabetes at baseline, stage II hypertension, stage I hypertension, and the use of ACEIs at discharge (odds ratio of .18, .24, .30 [P < .001], and .53 [P = .009], respectively). CONCLUSIONS: Despite clinical evidence of the benefits of the BP control in reduction of secondary stroke events, a substantial number of stroke patients in Thailand do not achieve their BP targets, and this could possibly be a result of inadequate use of antihypertensive therapies and lack of compliance to BP management guidelines.

The effect of cilostazol on carotid intima-media thickness progression in patients with symptomatic intracranial atherosclerotic stenosis.

BACKGROUND: The progression of carotid intima-media thickness (CIMT) is closely associated with ischemic stroke recurrence. However, the efficacy of cilostazol on preventing CIMT progression in stroke patients has never been investigated properly by a prospective trial. METHODS: This study is a part of "Trial of Cilostazol in Symptomatic Intracranial Arterial Stenosis-2." Six centers that are available to measure CIMT according to the protocol participated in this substudy. After 7 months of randomization, the changes of CIMT were compared between cilostazol group and clopidogrel group. CIMT was measured by a semiautomated software (Intimascope) and was presented as the mean of maximum (CIMT-max) and average (CIMT-ave) of both common carotid arteries. Linear logistic regression analysis and analysis of covariance were performed to verify the independent factors associated with CIMT progression. RESULTS: Among the 85 patients, 39 subjects were assigned to cilostazol group and 46 subjects to clopidogrel group. Follow-up CIMT significantly decreased in cilostazol group (CIMT-max: -.03 ± .11 and CIMT-ave: -.02 ± .08) compared with the increase in clopidogrel group (CIMT-max: .04 ± .20 and CIMT-ave: .04 ± .11; P = .05 and P = .04, respectively). Female, diabetes, and smoking were independently associated with the progression of CIMT, whereas the use of cilostazol was against CIMT progression from the results of linear regression analysis (P = .03 for both CIMT-max and CIMT-ave). The use of cilostazol also well predicted less progression of CIMT at follow-up after adjusting for baseline CIMT values and conventional risk factors (CIMT-max: P = .04 and CIMT-ave: P = .03). CONCLUSION: Cilostazol has a beneficial effect in preventing the progression of CIMT in ischemic stroke patients.

Arcanobacterium pyogenes endocarditis: a case report and literature review.

We report the case of a 64-year-old man with Arcanobacterium pyogenes endocarditis. The patient presented with dyspnea and asymmetrical progressive quadriparesis. A transthoracic echocardiogram revealed mobile vegetations on both leaflets of his mitral valve measuring 0.5 x 3 cm, thickening of the mitral valve with severe mitral regurgitation due to dehiscence of the papillary muscle to the posterior mitral leaflet. He also had aortic sclerosis with a vegetation measuring 0.5 x 1 cm causing aortic valve dehiscence and free flow aortic regurgitation. An initial hemoculture grew out pleomorphic, gram-positive, non-motile, anaerobic to microaerophilic bacilli. A diagnosis of infective endocarditis was made using modified Duke criteria. He was treated with intravenous ampicillin and gentamicin. Four days after admission, he developed acute respiratory failure and succumbed to the disease. A pre-mortem hemoculture and post-mortem heart valve culture grew Arcanobacterium pyogenes. Septic thromboemboli involving the brain, kidneys, lungs and spleen were documented. The patient also had ischemic vasculopathy with focal spinal arteriolitis and bilateral demyelination of the cervical corticospinal tracts. There are three published reports of human A. pyogenes endocarditis in the literature. Neurological involvement with ischemic spinal vasculopathy and demyelination has not been reported. We report the first autopsy proven case of A. pyogenes infective endocarditis with ischemic spinal vasculopathy. We review the clinicopathologic features of systemic A. pyogenes infection.

Coexistent extra- and intracranial stenosis, cervical atherosclerosis, and abnormal ankle brachial index in acute ischemic stroke.

BACKGROUND: There are limited data regarding abnormal ankle brachial index (ABI) with coexistent extracranial carotid stenosis (ECS), intracranial stenosis (ICS), and nonstenotic cervical atherosclerosis (CAS) in stroke, especially in Asia. METHODS: We studied the prevalence of ECS, ICS, CAS, and combined ECS and ICS in 756 Thai patients with acute ischemic stroke and correlated sites of atherosclerosis with stroke risk factors and abnormal ABI. RESULTS: The prevalence of ECS was 8.8%, ICS 52.6%, CAS 36.0%, abnormal ABI 18.8%, combined ECS and ICS 4.6%, combined ECS and abnormal ABI 2.8%, combined ICS and abnormal ABI 10.6%, and combined ECS, ICS, and abnormal ABI 1.6%. The prevalence of ECS, CAS, and combined ECS and ICS was higher in abnormal ABI compared to normal ABI (14.8% v 7.5% [P = .006]; 46.5% v 33.5% [P = .004], and 8.4% v 3.7% [P = .016], respectively). ECS was significantly correlated with history of coronary artery disease (CAD) and abnormal ABI; ICS with male gender, no alcohol use, and no atrial fibrillation; CAS with age ≥ 60 years, history of CAD and abnormal ABI; and combined ECS and ICS with history of CAD. CONCLUSIONS: The frequency of atherosclerosis, especially ICS, was high. Cervicocerebral atherosclerosis was higher in abnormal ABI. This suggests that ischemic stroke patients should be screened for ECS, CAS, ICS, and abnormal ABI, especially in specific subsets (age ≥ 60 years, male gender, and history of CAD). The improved identification of vascular lesions could allow for a more optimal choice of antithrombotics, neurointervention, and more aggressive control of risk factors, potentially improving prevention of disease progression and a decrease in recurrent vascular events.

Prevalence and association between risk factors, stroke subtypes, and abnormal ankle brachial index in acute ischemic stroke.

BACKGROUND: Abnormal ankle brachial index (ABI) identifies a stroke subgroup with high risk of subsequent stroke and other vascular events. There are few data regarding the prevalence of abnormal ABI in ischemic stroke in Asian countries. METHODS: We evaluated the prevalence of abnormal ABI in 747 Thai patients with ischemic stroke or transient ischemic attack and assessed the correlation of abnormal ABI with stroke risk factors and stroke subtypes. RESULTS: The prevalence of abnormal ABI (≤0.9) in ischemic stroke patients was 18.1%. Abnormal ABI in ischemic stroke patients was significantly correlated with female gender (odds ratio [OR], 1.61; confidence interval [CI], 1.09-2.40; P = .017), age ≥ 60 years (OR, 3.54; CI, 2.14-5.85; P < .001), and previous ischemic events, including coronary artery disease (OR, 2.55; CI, 1.47-4.43; P = .001), cerebrovascular disease (OR, 2.15; CI, 1.37-3.55; P = .002), and atrial fibrillation (OR, 1.71; CI, 1.03-2.82; P = .036). There was a significant difference in the prevalence of abnormal ABI among stroke subtypes (P < .001), which tended to be more frequent in those with large artery disease (20.4%), cardioembolic stroke (29.2%), and undetermined etiology (20.6%). CONCLUSIONS: An ABI examination should be considered in patients with ischemic stroke to facilitate the early detection and treatment of asymptomatic peripheral arterial disease and identification of excess risk for subsequent stroke or other vascular events.

Thai venous stroke prognostic score: TV-SPSS.

BACKGROUND AND OBJECTIVE: Prognosis of cerebral venous sinus thrombosis (CVST) has never been studied in Thailand. A simple prognostic score to predict poor prognosis of CVST has also never been reported. The authors are aiming to establish a simple and reliable prognostic score for this condition. MATERIAL AND METHOD: The medical records of CVST patients from eight neurological training centers in Thailand who received between April 1993 and September 2005 were reviewed as part of this retrospective study. Clinical features included headache, seizure, stroke risk factors, Glasgow coma scale (GCS), blood pressure on arrival, papilledema, hemiparesis, meningeal irritation sign, location of occluded venous sinuses, hemorrhagic infarction, cerebrospinal fluid opening pressure, treatment options, length of stay, and other complications were analyzed to determine the outcome using modified Rankin scale (mRS). Poor prognosis (defined as mRS of 3-6) was determined on the discharge date. RESULTS: One hundred ninety four patients' records, 127 females (65.5%) and mean age of 36.6 +/- 14.4 years, were analyzed Fifty-one patients (26.3%) were in the poor outcome group (mRS 3-6). Overall mortality was 8.4%. Univariate analysis and then multivariate analysis using SPSS version 11.5 revealed only four statistically significant predictors influencing outcome of CVST They were underlying malignancy, low GCS, presence of hemorrhagic infarction (for poor outcome), and involvement of lateral sinus (for good outcome). Thai venous stroke prognostic score (TV-SPSS) was derived from these four factors using a multiple logistic model. CONCLUSION: A simple and pragmatic prognostic score for CVST outcome has been developed with high sensitivity (93%), yet low specificity (33%). The next study should focus on the validation of this score in other prospective populations.

Comparison of Computerized and Standard Cognitive Test in Thai Memory Clinic.

BACKGROUND: Computer-based Thai Cognitive Test or Computer-based Thai Mental State Examination (cTMSE) was developed aiming to help doctors to easily get the accurate results of TMSE in a routine, busy outpatient clinics. The purpose of this study was to compare the evaluation process in terms of feasibility, duration of the test, participants/administrator preference, and the results of cognitive test between cTMSE and the standard Thai Mental State Examination (sTMSE). METHODS: Twenty-two elderly participants (>60 years old) who were not demented and 22 patients with mild-to-moderate dementia were included in the study. All participants would be asked to have TMSE by standard method (sTMSE) and computer-based method (cTMSE), at least 2 weeks and up to 2 months apart. Scores and duration of the test were compared using dependent paired t-test. Agreement of the tests between two methods and Kappa statistics were analyzed. RESULTS: Paired t-test showed no significant difference in scores between the two methods (mean sTMSE vs. cTMSE: 22.84 vs. 22.62, 95% confidence interval [CI]: [-0.465] to 0.987, P = 0.524). Percent of agreement between the two methods was 92.5%, with the Kappa of 0.85 (P < 0.001). Duration of the test by sTMSE was slightly shorter than the cTMSE (7.31 min vs. 7.97 min, 95% CI: [-1.159] to [-0.175], P = 0.09). Overall, participants liked being tested by cTMSE more than sTMSE. CONCLUSION: Computer-based TMSE was feasible to use and accurate for screening in aging adults and for cognitive evaluation in patients with mild-to-moderate dementia.

Noninvasive ultrasound evaluation of the vertebral artery in hypertension.

BACKGROUND AND PURPOSE: Surgical decompression of the vascular loop of the vertebral artery (VA) at the left lateral medulla can reduce blood pressure (BP) in hypertension, and a larger diameter of the left VA has been found in hypertensive patients. Noninvasive evaluation of the VA in hypertension may assist selecting patients for more appropriate diagnosis and treatment. Duplex ultrasonography is used to study the relationship between VA diameter and BP. METHODS: A retrospective review of VA duplex ultrasonography was performed in 112 consecutive patients who were sent to the neurovascular laboratory at the Wake Forest University School of Medicine during a 2-month period. All measurements (BP, pulse rate, peak systolic velocity [PSV], end diastolic velocity [EDV], and diameters of both VAs) were determined according to standardized protocols. Left-right comparisons of VA diameters, PSV, and EDV between hypertensives and normotensives were performed by the matched-pairs analysis techniques. RESULTS: Fifty-five women and 57 men with a mean age of 64.8 years were studied. Hypertension was present in 65.2% of all patients. The age-adjusted mean left VA diameter was significantly higher than that of the right VA with an age-adjusted average differences of 0.2 mm (P = .03) for hypertensives compared to 0.04 mm (P = .75) for normotensives. No significant differences were observed in either PSV or EDV. CONCLUSIONS: Differences in left-right VA diameter in hypertensive subjects may be a previously unrecognized component of the vascular disturbances associated with the disease and represent an additional criterion for identifying those who may benefit from surgical and medical management.

Pitfall of electron beam computed tomography angiography in diagnosis of subclavian steal syndrome.

A patient presented with vertebrobasilar insufficiency during exertion. Vertebral duplex and transcranial Doppler ultrasonography showed reversal of flow in both intracranial and extracranial vertebral and basilar arteries, suggesting bilateral subclavian and vertebrobasilar steal. Electron beam computed tomography angiography (CTA) showed no evidence of subclavian artery stenosis including normal vertebral artery origin on both sides. However, digital subtraction angiography revealed complete occlusion of both subclavian arteries with retrograde flow from both vertebral and basilar arteries to reconstitute both subclavian arteries. This false-negative finding on CTA in detection of subclavian steal syndrome (SSS) is due to inappropriate contrast administration technique and postprocessing method, inability to differentiate flow direction, and lack of hemodynamic time sequences. This study demonstrates a pitfall of CTA in diagnosis of SSS compared to more reliable hemodynamic information obtained by duplex and transcranial Doppler ultrasonography, and digital subtraction angiography.

Dual antiplatelets reduce microembolic signals in patients with transient ischemic attack and minor stroke: subgroup analysis of CLAIR study.

BACKGROUND: Short course of dual antiplatelet therapy for early secondary prevention is a promising treatment for patients with minor stroke or transient ischemic attack at high risk of recurrence. METHODS: We examined the efficacy and safety of dual antiplatelets in patients with transient ischemic attack or minor stroke, defined as National Institute of Health Stroke Scale scores 0-3, in a subgroup analysis of Clopidogrel plus aspirin versus Aspirin alone for Reducing embolization in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR) study. Microembolic signals on transcranial Doppler monitoring was used as surrogate marker for recurrent stroke risk. Patients with ≥1 microembolic signals at baseline were randomized to receive dual therapy (aspirin 75-160 mg daily and clopidogrel 300 mg day 1 then 75 mg daily) or monotherapy (aspirin 75-160 mg daily) for seven-days. RESULTS: Sixty-five of 100 patients recruited had transient ischemic attack or minor stroke: 30 received dual therapy and 35 received monotherapy. Mean onset-to-randomization was 2·3 days in dual therapy group and 3·2 days in monotherapy group (P = 0·03). At day 7, the proportion of patients with ≥1 microembolic signals was 9 of 29 patients in dual therapy group and 18 of 34 patients in monotherapy group (adjusted relative risk reduction 41·4%, 95% CI 29·8-51·1, P < 0·001). The median number of microembolic signals on day 7 was 0 in dual therapy group and 1·0 in monotherapy group (P = 0·046). No patients had intracranial or severe systemic hemorrhage. CONCLUSIONS: Early dual therapy with clopidogrel and aspirin reduces microembolic signals in patients with minor ischemic stroke or transient ischemic attack, without causing significant bleeding complications.

Prevalence and predictors of carotid stenosis in Thai patients with ocular disorders.

There are limited data on prevalence and predictors of carotid stenosis (CS) in Thai and Asian patients with ocular disorders. A total of 135 of 2849 patients enrolled in the Neurosonology Registry had an ocular indication (OI). Demographics, the nature of the OI, risk factors (RF), presence of CS >50% and non-stenotic carotid plaque (NSCP) were analyzed. The mean age of patients was 60.40 ± 14.02 years. The RF included hypertension (47.4%), hypercholesterolemia (34.07%), diabetes mellitus (DM) (31.11%) and current smoking (41.48%). NSCP was found in 20% of Thai patients with OD. CS was found in 11.11% (ipsilateral 10.37%). Predictors of CS were ocular ischemic syndrome (odds ratio [OR] 19.63, p = 0.000), retinal artery occlusion (OR 14.13, p = 0.000), anterior ischemic optic neuropathy (OR 9.75, p = 0.002), neovascularized glaucoma (OR 8.15, p = 0.018), and DM (OR 2.53, p = 0.037). The presence of CS (11.11%), and CS or NSCP (31%) are markers of atherosclerotic risk. The nature of the OI predicted carotid findings. Carotid ultrasound helps to identify the risk for cardiovascular events and should be considered in patients with OI.

Stroke fast track reduces time delay to neuroimaging and increases use of thrombolysis in an academic medical center in Thailand.

Delays between hospital arrival and neuroimaging prevented patients from receiving thrombolysis. We report impact of Stroke Fast Track (SFT) on time to imaging, and rates of recombinant tissue plasminogen activator (rt-PA) in eligible patients. Characteristics, time intervals, and rates of rt-PA were evaluated in 464 patients with suspected acute stroke within 7 days (2005-2006). Complete time intervals were available on 380. Median times between emergency room arrival, brain computerized tomography (CT), and CT results were 25 and 45 minutes, respectively, for patients arriving <3 hours from onset, 40, and 65 minutes for those arriving >3 hours, and 35 and 60 minutes for all patients, which is significantly shorter than 2.5 hours to CT in 2004, prior to SFT (P < .0001). Although not different in time to first physician, patients arriving >3 hours had longer times to CT and CT results (P < .001). Overall, 5.5% of ischemic stroke patients received intravenous rt-PA, including 27.1% of those arriving within 3 hours, which represented 100% of all eligible patients, compared with 0% in 2004. SFT reduced time delay in neuroimaging and increased use of rt-PA in Thailand. Continuous quality improvement is needed to achieve best results in each setting, and to insure optimal care for acute stroke patients.

Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR study): a randomised, open-label, blinded-endpoint trial.

BACKGROUND: Few randomised clinical trials have investigated the use of antithrombotic drugs for early secondary prevention of stroke or transient ischaemic attack in patients with intracranial atherosclerotic stenosis. Microembolic signals, detected by transcranial doppler, are a surrogate marker of future stroke risk and have been used to show treatment efficacy in patients with extracranial carotid stenosis. We aimed to investigate whether treatment with clopidogrel plus aspirin reduced the number of microembolic signals detected with transcranial doppler ultrasound compared with aspirin alone in patients with recent stroke. METHODS: The clopidogrel plus aspirin for infarction reduction in acute stroke or transient ischaemic attack patients with large artery stenosis and microembolic signals (CLAIR) trial was a randomised, open-label, blinded-endpoint trial. Between Oct 28, 2003, and Nov 19, 2008, patients with acute ischaemic stroke or transient ischaemic attack who had symptomatic large artery stenosis in the cerebral or carotid arteries and in whom microembolic signals were present on transcranial doppler were randomly assigned within 7 days of symptom onset to receive clopidogrel (300 mg for the first day, then 75 mg daily) plus aspirin (75-160 mg daily) or aspirin alone (75-160 mg daily) for 7 days. Patients were randomly assigned in blocks of four or six by use of a randomisation website. Monitoring of microembolic signals on transcranial doppler was done on days 2 and 7. The primary endpoint was the proportion of patients who had microembolic signals on day 2. Analysis was by modified intention to treat. All analyses were done by an investigator masked to both patient identity and the day the recording was taken. This trial is registered with the Centre for Clinical Trials, Chinese University of Hong Kong, number CUHK_CCT00164. FINDINGS: 100 patients were randomly assigned to clopidogrel plus aspirin (n=47) or aspirin monotherapy (n=53). 93 of 100 patients had symptomatic intracranial stenosis in either the intracranial internal carotid artery or the middle cerebral artery: 45 of 46 in the dual therapy group and 48 of 52 in the monotherapy group. At day 2, 14 of 45 patients in the dual therapy group and 27 of 50 patients in the monotherapy group for whom data were available had at least one microembolic signal on transcranial doppler (relative risk reduction 42.4%, 95% CI 4.6-65.2; p=0.025). Adverse events were similar in the two groups. No patients had intracranial or severe systemic haemorrhage, but two patients in the dual therapy group had minor haemorrhages. INTERPRETATION: Combination therapy with clopidogrel and aspirin is more effective than aspirin alone in reducing microembolic signals in patients with predominantly intracranial symptomatic stenosis. Clinical trials are now warranted to investigate whether this combination treatment also results in a reduction in stroke incidence.

Detection of air microbubbles in the internal jugular vein after intravenous injection of contrast agent for the diagnosis of patent foramen ovale.

The use of agitated air and saline, injected intravenously, combined with monitoring of the middle cerebral artery using transcranial Doppler sonography, is an effective method for detecting paradoxic cerebral embolism caused by right-to-left intracardiac shunting. This technique is particularly useful in patients with a patent foramen ovale. In patients without temporal acoustic windows, the method can be modified by using sonographic monitoring of the common carotid artery. Observation of saline-contrast microbubbles in the internal jugular vein during this procedure suggests incompetence of the ipsilateral internal jugular valve. This noninvasive method may thus be useful for studying the competence of the internal jugular valve.