Intravenous Thrombolysis 4.5-9 Hours After Stroke Onset: A Cohort Study from the TRISP Collaboration.

OBJECTIVE: To investigate the safety and effectiveness of intravenous thrombolysis (IVT) >4.5-9 hours after stroke onset, and the relevance of advanced neuroimaging for patient selection. METHODS: Prospective multicenter cohort study from the ThRombolysis in Ischemic Stroke Patients (TRISP) collaboration. Outcomes were symptomatic intracranial hemorrhage, poor 3-month functional outcome (modified Rankin scale 3-6) and mortality. We compared: (i) IVT >4.5-9 hours versus 0-4.5 hours after stroke onset and (ii) within the >4.5-9 hours group baseline advanced neuroimaging (computed tomography perfusion, magnetic resonance perfusion or magnetic resonance diffusion-weighted imaging fluid-attenuated inversion recovery) versus non-advanced neuroimaging. RESULTS: Of 15,827 patients, 663 (4.2%) received IVT >4.5-9 hours and 15,164 (95.8%) within 4.5 hours after stroke onset. The main baseline characteristics were evenly distributed between both groups. Time of stroke onset was known in 74.9% of patients treated between >4.5 and 9 hours. Using propensity score weighted binary logistic regression analysis (onset-to-treatment time >4.5-9 hours vs onset-to-treatment time 0-4.5 hours), the probability of symptomatic intracranial hemorrhage (ORadjusted 0.80, 95% CI 0.53-1.17), poor functional outcome (ORadjusted 1.01, 95% CI 0.83-1.22), and mortality (ORadjusted 0.80, 95% CI 0.61-1.04) did not differ significantly between both groups. In patients treated between >4.5 and 9 hours, the use of advanced neuroimaging was associated with a 50% lower mortality compared with non-advanced imaging only (9.9% vs 19.7%; ORadjusted 0.51, 95% CI 0.33-0.79). INTERPRETATION: This study showed no evidence in difference of symptomatic intracranial hemorrhage, poor outcome, and mortality in selected stroke patients treated with IVT between >4.5 and 9 hours after stroke onset compared with those treated within 4.5 hours. Advanced neuroimaging for patient selection was associated with lower mortality. ANN NEUROL 2023;94:309-320.

Sex differences in outcome after carotid revascularization in symptomatic and asymptomatic carotid artery stenosis.

OBJECTIVE: Sex differences regarding the safety and efficacy of carotid revascularization in carotid artery stenosis have been addressed in several studies with conflicting results. Moreover, women are underrepresented in clinical trials, leading to limited conclusions regarding the safety and efficacy of acute stroke treatments. METHODS: A systematic review and meta-analysis was performed by literature search including four databases from January 1985 to December 2021. Sex differences in the efficacy and safety of revascularization procedures, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), for symptomatic and asymptomatic carotid artery stenoses were analyzed. RESULTS: Regarding CEA in symptomatic carotid artery stenosis, the stroke risk in men (3.6%) and women (3.9%) based on 99,495 patients (30 studies) did not differ (P = .16). There was also no difference in the stroke risk by different time frames up to 10 years. Compared with men, women treated with CEA had a significantly higher stroke or death rate at 4 months (2 studies, 2565 patients; 7.2% vs 5.0%; odds ratio [OR], 1.49; 95% confidence interval [CI], 1.04-2.12; I2 = 0%; P = .03), and a significantly higher rate of restenosis (1 study, 615; 17.2% vs 6.7%; OR, 2.81; 95% CI, 1.66-4.75; P = .0001). For CAS in symptomatic artery stenosis, data showed a non-significant tendency toward higher peri-procedural stroke in women, whereas for asymptomatic carotid artery stenosis, data based on 332,344 patients showed that women (compared with men) after CEA had similar rates of stroke, stroke or death, and the composite outcome stroke/death/myocardial infarction. The rate of restenosis at 1 year was significantly higher in women compared with men (1 study, 372 patients; 10.8% vs 3.2%; OR, 3.71; 95% CI, 1.49-9.2; P = .005). Furthermore, CAS in asymptomatic patients was associated with low risk of a postprocedural stroke in both sexes, but a significantly higher risk of in-hospital myocardial infarction in women than men (8445 patients, 1.2% vs 0.6%; OR, 2.01; 95% CI, 1.23-3.28; I2 = 0%; P = .005). CONCLUSIONS: A few sex-differences in short-term outcomes after carotid revascularization for symptomatic and asymptomatic carotid artery stenosis were found, although there were no significant differences in the overall stroke. This indicates a need for larger multicenter prospective studies to evaluate these sex-specific differences. More women, including those aged over 80 years, need to be enrolled in randomized controlled trials, to better understand if sex differences exist and to tailor carotid revascularization accordingly.

Intravenous Thrombolysis in Patients With Ischemic Stroke Aged ≥90 Years: A Cohort Study From the TRISP Collaboration.

BACKGROUND: The probability to receive intravenous thrombolysis (IVT) for treatment of acute ischemic stroke declines with increasing age and is consequently the lowest in very elderly patients. Safety concerns likely influence individual IVT treatment decisions. Using data from a large IVT registry, we aimed to provide more evidence on safety of IVT in the very elderly. METHODS: In this prospective multicenter study from the TRISP (Thrombolysis in Ischemic Stroke Patients) registry, we compared patients ≥90 years with those <90 years using symptomatic intracranial hemorrhage (ECASS [European Cooperative Acute Stroke Study]-II criteria), death, and poor functional outcome in survivors (modified Rankin Scale score 3-5 for patients with prestroke modified Rankin Scale score ≤2 and modified Rankin Scale score 4-5 for patients prestroke modified Rankin Scale ≥3) at 3 months as outcomes. We calculated adjusted odds ratio with 95% CI using logistic regression models. RESULTS: Of 16 974 eligible patients, 976 (5.7%) were ≥90 years. Patients ≥90 years had higher median National Institutes of Health Stroke Scale on admission (12 versus 8) and were more often dependent prior to the index stroke (prestroke modified Rankin Scale score of ≥3; 45.2% versus 7.4%). Occurrence of symptomatic intracranial hemorrhage (5.7% versus 4.4%, odds ratioadjusted 1.14 [0.83-1.57]) did not differ significantly between both groups. However, the probability of death (odds ratioadjusted 3.77 [3.14-4.53]) and poor functional outcome (odds ratioadjusted 2.63 [2.13-3.25]) was higher in patients aged ≥90 years. Results for the sample of centenarians (n=21) were similar. CONCLUSIONS: The probability of symptomatic intracranial hemorrhage after IVT in very elderly patients with stroke did not exceed that of their younger counterparts. The higher probability of death and poor functional outcome during follow-up in the very elderly seems not to be related to IVT treatment. Very high age itself should not be a reason to withhold IVT.

Cerebral venous thrombosis: a retrospective unicentric analysis of clinical and neuroimaging characteristics.

Thrombosis of dural sinuses and/or cerebral veins (CVT) is an uncommon form of stroke, usually affecting young individuals. It has a variable clinical presentation ranging from mild cases presenting only headaches, to severe cases featuring encephalopathy, coma or status epilepticus. A retrospective cross-sectional study of patients treated in the outpatient department and in-hospital during the period from 2014 to 2020 at the Neurology Clinic-University Clinical Centre of Serbia was conducted. Forty-nine patients (24 men; 25 women) were included in the study. Twenty-three patients (46.9%) suffered a subacute form of CVT (48 h-4 weeks), 19 (38.8%) presented with an acute form (< 48 h) and 7 (14.3%) with a chronic form (> 4 weeks). Around 75% of patients reported headaches during disease course. Focal neurological deficit (FND) was observed in 27 (55.1%) patients. Patients who did not report headaches (22.4%) presented with more severe symptoms (seizures and coma). More than 70% of patients had no radiologically evident brain parenchymal lesion. The most frequent locations of CVT were transverse sinus (79.6%), sigmoid sinus (44.9%) and superior sagittal sinus (36.7%). Thrombosis of more than one sinus/vein occurred in 33 (67.3%) patients. Hereditary thrombophilia was observed in 9 (18.4%) patients, 11 (22.4%) patients had some type of infection and 20% of women reported OCT usage. As much as 25% of cases remained without evident risk factors. The most common symptom in our cohort was acute unilateral throbbing headache of high intensity, while patients without headaches had more severe symptoms.

Myasthenia gravis treated in the neurology intensive care unit: a 14-year single-centre experience.

INTRODUCTION: Severe myasthenia gravis (MG) exacerbation with respiratory failure and/or dysphagia usually requires monitoring and treatment in the neurology intensive care unit (NICU). The aim of our study was to identify all patients with severe MG exacerbation treated in the NICU in order to assessed potential factors affecting patients' need for mechanical ventilation, occurrence of complications and the final outcome. METHODS: We retrospectively included all patients with severe exacerbation of MG who required management in the NICU during a 14-year period. Baseline sociodemographic and clinical features, data on medication, comorbidities and outcome were obtained by reviewing medical records and institutional databases. RESULTS: Our study comprised 130 severe MG exacerbations detected in 118 patients. Median age of patients was 61.5 years, and women accounted for 58.5% of the patients. Half of the patients required mechanical ventilation during hospitalization. Lethal outcome was observed in 12.3% of severe MG exacerbations. Only elder age was an independent negative predictor of survival (OR 0.89, 95% CI 0.82-0.97, p < 0.01). Complications during hospitalization were detected in 50% of patients. A higher number of comorbidities (OR 1.09, 95% CI 1.60-2.35, p = 0.01) and mechanical ventilation (OR 28.48, 95% CI 8.56-94.81, p < 0.01) were independent predictors of complications during hospitalization. CONCLUSION: Patients with a severe MG exacerbation who do not require mechanical ventilation have a good outcome after treatment in the NICU. Elder age is an independent predictor of lethal outcome in patients with severe MG exacerbation. Mechanical ventilation and a higher number of comorbidities lead to more frequent complications.

Guillain-Barré syndrome during pregnancy: A case series.

Guillain-Barré syndrome (GBS) in pregnancy may be a serious disease associated with high maternal and perinatal morbidity and mortality. Herein, we present the long-term maternal and fetal outcomes of five pregnant GBS patients from our center. The mean age of pregnant GBS patients was 29.8 ± 3.1. Two patients had a severe disability at admission. Three patients were treated with intravenous immunoglobulins, while the remaining two were treated with symptomatic therapy. One year after disease onset, one patient had a mild disability, while the remaining four had normal neurological findings. All babies born were healthy and developed normally. GBS in pregnancy may affect both maternal and neonatal outcomes. Early diagnosis and treatment are essential for the outcome. Most patients and their babies have a favorable long-term outcome.

Atrial fibrillation is associated with poor long-term outcome after mechanical thrombectomy for anterior large vessel occlusion stroke.

OBJECTIVES: Atrial fibrillation (AF) is one of the leading causes of acute ischemic stroke (AIS). The aim of our study was to determine the influence of AF on the long-term outcome of patients with AIS due to anterior circulation large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). METHODS: Our study included 127 consecutive patients with AIS due to anterior LVO who underwent MT between January 2018 and March 2020. Demographics, clinical, radiological and treatment characteristics were prospectively collected. Modified Rankin scale (mRS) score ≤2 was defined as a good functional outcome. RESULTS: AF was detected in 62 (48.8%) patients. Patients with AF were elder (73.1 ± 8.7 vs. 58.5 ± 14.2 years, p<0.01) and usually female (56.5% vs. 36.9%, p=0.03). They had a lower percentage of good functional outcome (31.6% vs. 62.3%, p<0.01) and a higher mortality rate (47.5% vs. 18.5%, p<0.01) after one year of follow-up. In the multivariate logistic regression the variables that showed significance with p <0.05 in previous univariate analyses were included. The presence of AF (aOR 0.29, 95% CI 0.11-0.78, p=0.01) and initial NIHSS score >15 (aOR 0.25, 95% CI 0.11-0.56, p<0.01) were independent negative predictors of good functional outcome after one year of follow-up. However, the presence of AF did not affect all-cause mortality within one year (p=0.18). CONCLUSION: AF and initial NIHSS score >15 are independent negative predictors of good long-term functional outcome in patients with AIS due to anterior circulation LVO treated with MT.

Influence of Thrombocytopenia on the Outcome of Mechanical Thrombectomy in Patients with Acute Ischemic Stroke.

OBJECTIVES: Mechanical thrombectomy (MT) has become leading treatment option for acute ischemic stroke (AIS) due to large vessels occlusion (LVO). Platelet counts may affect outcome in patients with AIS or transient ischemic attack. The aim of our study was to determine the influence of thrombocytopenia on the safety and efficacy of MT in patients with AIS due to anterior circulation LVO. MATERIALS AND METHODS: This study included 127 consecutive adult patients with AIS due to anterior circulation LVO who underwent MT. The patients were divided into 2 groups based on initial platelet count: with thrombocytopenia (<150 × 109/L) and without thrombocytopenia (≥150 × 109/L). Primary safety outcome was symptomatic intracerebral haemorrhage (SICH), while secondary safety outcome was stroke-related mortality. Efficacy outcome was functional independence, defined as modified Rankin Scale (mRS) score 0-2. Follow- up time was 90 days. RESULTS: Initial thrombocytopenia (<150 × 109/L) was detected in 19 (15%) patients. Multivariable analysis showed that initial thrombocytopenia did not increase the risk of SICH and did not affect the short-term functional outcome (p = 0.587). However, initial thrombocytopenia increased the risk for stroke-related mortality (aOR 3.639, 95% CI 1.079-12.641, p = 0.037). The main cause of mortality in the group with thrombocytopenia was malignant cerebral infarction (44.4%). CONCLUSIONS: Thrombocytopenia does not affect the efficacy and the risk of SICH in patients with AIS caused by anterior circulation LVO treated with MT. However, the risk of mortality is higher in patients with thrombocytopenia, mainly due to malignant cerebral infarction.

Incidence and mortality rates of Guillain-Barré syndrome in Serbia.

Guillain-Barré syndrome (GBS) is an acute auto-immune polyradiculoneuropathy. A huge variety of GBS incidence and mortality rates has been noted across the world. The objective of the present multi-centric study was to assess the incidence and mortality rates of GBS during a 10-year period in Serbia. We collected data of adult GBS patients who were hospitalized from 2009 to 2018 in all five tertiary healthcare centers in Serbia. The incidence rates per 100 000 inhabitants with 95% confidence intervals (CI) were calculated and further corrected for the estimated number of patients hospitalized in secondary centers. Mortality rates were also assessed. GBS was considered severe if patients were not able to walk at least 10 m without assistance. Six hundred and forty GBS patients were registered in tertiary centers in a 10-year period. The proportion of severe cases was 75% at nadir, and 52% on discharge. GBS incidence rate in Serbia was 1.1 per 100 000 inhabitants, and estimated incidence if patients from secondary centers included 1.2 per 100 000. Peak incidence was observed during the sixth decade of life. During the acute phase, 5.6% of GBS patients died, while overall 9.7% of them died during 6-month period from disease onset. This study contributes to our knowledge about GBS epidemiology. Results will allow us to improve the diagnosis and treatment of GBS patients in Serbia.

Six-month prospective study of quality of life in Guillain-Barre syndrome.

OBJECTIVE: Guillain-Barre syndrome (GBS) is an acute disease of the peripheral nerves and their roots. Quality of life (QoL) in the first year after acute episode of GBS is still underresearched area. The aim of our study was to investigate QoL in GBS patients during a 6-month follow-up period. METHODS: Multicentric, prospective study included 74 adult patients with GBS (54% males). GBS disability scale (GDS) was used to assess functional disability (severe disability GDS > 2), and Individualized Neuromuscular Quality of Life Questionnaire (INQoL) to asses QoL. Patients were tested on day 14, day 28, month 3, and month 6 from symptom onset. RESULTS: Disability as measured by GDS improved during time (P < .01). INQoL scores also improved during time (P < .01) but were not able to differentiate between day 14 and day 28, and some scores also did not make difference between month 3 and 6 (pain, social relations, emotions and total INQoL score; P > .05). Pooled GDS scores correlated with pooled INQoL scores, especially with independence, activities, and weakness subscores (P < .01). Multiple linear regression analysis showed that GDS at day 14 (ß = .52, P < .01) and fatigue score at day 14 (ß = .41, P < .01) were independent predictors of the worse GDS at month 6 (adjusted R2  = .34, P < .01 for overall model). CONCLUSIONS: During a 6-month follow-up period of GBS patients, we observed a gradual recovery of patients' disability and QoL. Our study confirms the importance of patient-reported outcomes and their ability to capture some important issues that are omitted by classic ability measures such as GDS.

The Enzyme-Free Release of Nucleotides from Phosphoramidates Depends Strongly on the Amino Acid.

Phosphoramidates composed of an amino acid and a nucleotide analogue are critical metabolites of prodrugs, such as remdesivir. Hydrolysis of the phosphoramidate liberates the nucleotide, which can then be phosphorylated to become the pharmacologically active triphosphate. Enzymatic hydrolysis has been demonstrated, but a spontaneous chemical process may also occur. We measured the rate of enzyme-free hydrolysis for 17 phosphoramidates of ribonucleotides with amino acids or related compounds at pH 7.5. Phosphoramidates of proline hydrolyzed fast, with a half-life time as short as 2.4 h for Pro-AMP in ethylimidazole-containing buffer at 37 °C; 45-fold faster than Ala-AMP and 120-fold faster than Phe-AMP. Crystal structures of Gly-AMP, Pro-AMP, ßPro-AMP and Phe-AMP bound to RNase A as crystallization chaperone showed how well the carboxylate is poised to attack the phosphoramidate, helping to explain this reactivity. Our results are significant for the design of new antiviral prodrugs.

Three-Year Follow-Up Study in Patients with Guillain-Barré Syndrome.

A majority of patients with Guillain-Barré syndrome (GBS) have tendency of a good recovery. Our aim was to evaluate the outcome of the disease 1 and 3 years after GBS symptom onset. METHODS: During 2014, GBS was diagnosed in 82 patients in seven tertiary healthcare centers. Neurological follow-up was conducted in 57 (70%) patients after 1 year, and in 54 (66%) after 3 years. Functional disability was estimated according to the GBS disability scale (GDS), with a score of 0-3 indicating mild disability and a score of 4-6 indicating severe disability during acute phase, whereas a score >1 indicated poor recovery on follow-ups. Visual analog scale was used to assess sensory symptoms and musculoskelatal pain, and Krupp's Fatigue Severity Scale was used to asses fatigue. RESULTS: Poor functional outcome was found in 39% of GBS patients at year 1 and 30% at year 3. Paresthesias/dysesthesias were detected in 60% of patients after 1 year and 43% after 3 years. Musculoskeletal pain was present in 40% of patients at year 1 and 33% at year 3. Significant fatigue after 1 year was found in 21% of subjects and after 3 years in 7%. Parameters associated with poor functional outcome after 1 year were age >55 years (p=0.05), severe disability at admission (p1 indique une récupération difficile au moment des suivis. L'échelle visuelle analogue (EVA) a aussi été utilisée pour évaluer leurs symptômes sensoriels et leurs douleurs musculo-squelettiques. Enfin, l'échelle de gravité de la fatigue de Krupp a été utilisée pour évaluer leur degré de fatigue. Résultats: La première année, on a observé une piètre amélioration des capacités fonctionnelles chez 39% des patients atteints du SGB; pour la troisième année, cette proportion était de 30%. Au bout d'un an, on a aussi détecté la présence de paresthésie/dysesthésie chez 60% des patients; pour la troisième année, cette proportion était de 43%. Des douleurs musculo-squelettiques ont été rapportées chez 40% des patients après un an; deux ans plus tard, ce pourcentage chutait à 33%. Enfin, un état de fatigue important a été noté chez 21% des patients au bout d'un an; ce pourcentage n'était plus que de 7% au bout de trois ans. Les paramètres associés à une piètre amélioration des capacités fonctionnelles au bout d'un an étaient l'âge (>55 ans; p=0,05) ainsi qu'une incapacité sévère au moment de leur admission (p<0,05) et de leur congé (p<0,01). Au bout de trois ans, une piètre amélioration des capacités fonctionnelles était associée au sexe masculin (p<0,05) et à une incapacité sévère au moment d'obtenir un congé (p=0,06). CONCLUSIONS: Un an et trois ans après l'apparition des premiers symptômes du SGB, un nombre important de patients donnaient à voir des séquelles neurologiques, ce qui incluait une forme ou une autre d'incapacité fonctionnelle, des symptômes sensoriels, des douleurs et un état de fatigue.

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.

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.

Clinical characteristics and outcome in the acute phase of ischemic locked-in syndrome: case series of twenty patients with ischemic LIS.

BACKGROUND: Locked-in syndrome (LIS) is a condition characterized by quadriplegia and anarthria. The most common cause is a ventral pontine lesion due to atherosclerotic basilar artery disease. METHODS: Cases with LIS were prospectively identified among the patients with acute ischemic stroke over 3 years, between 2009 and 2011. Clinical characteristics, topographic localization of lesions, and outcome were determined during the first 6 months from onset of LIS. RESULTS: Our case series consists of 20 patients (mean age 62 ± 10 years; range 46-82). Initially 16 patients had a reduced level of consciousness (mean 3 days; range 1-15). Respiratory disturbance, mainly as impairment of the breathing pattern, was noted in all cases. Five patients died within the first 10 days due to stroke progression or cardiac arrest. In the remaining cases the most frequent causes of death were pulmonary infections and sepsis. Overall mortality in the acute phase of LIS is 75%, and the median survival time is 42 days. There was a statistically significant association between the more extensive parenchymal brain stem lesions and observed mortality. CONCLUSIONS: Ischemic LIS is commonly caused by an acute complete occlusion of the basilar artery due to atherosclerotic lesions in intracranial vertebrobasilar vessels. Mortality remains high in the acute phase of the disease.

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.