RESUMO
BACKGROUND AND PURPOSE: Subclinical atrial fibrillation (AF) is known to underlie a number of cases of cryptogenic stroke (CrS). However, there is need to define the most effective strategy for AF detection. The diagnostic usefulness was analysed of a strategy based on ultra-early continuous monitoring in patients with CrS in terms of AF detection, oral anticoagulation treatment and stroke recurrence, in comparison to a standard outpatient strategy. METHODS: Patients with ischaemic stroke of undetermined origin and confirmed to be cryptogenic after extensive work-up were searched for AF with (i) a conventional strategy (historical cohort, n = 101) with serial electrocardiograms and 24-h Holter monitoring or (ii) an ultra-early monitoring strategy with insertable cardiac monitor (ICM) implanted before discharge (prospective cohort, n = 90). AF episodes lasting >1 min, anticoagulant treatment and stroke recurrence were recorded. RESULTS: During admission, AF was similarly detected in both cohorts (24% of patients). After discharge (mean follow-up 30 ± 10 months), AF detection rates were 17/80 (21.3%) and 38/65 (58.5%) for patients in the conventional versus the ultra-early ICM group (P < 0.001). Up to 41% of AF cases in the ICM cohort were detected within the first month. Oral anticoagulation was initiated in 37.6% versus 65.5% (P < 0.001) and stroke recurrence was recorded in 10.9% versus 3.3% (P 0.04) in the conventional versus the ICM cohort. CONCLUSIONS: Pre-discharge ICM implant allows detection of AF during follow-up in up to 58% of selected patients with CrS. Compared to a conventional strategy, ultra-early ICM implant results in higher anticoagulation rates and a decrease in stroke recurrence.
Assuntos
Fibrilação Atrial/diagnóstico , Coração/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/etiologia , Estudos de Coortes , Eletrocardiografia Ambulatorial , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Neurofisiológica , Prognóstico , Acidente Vascular Cerebral/complicações , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Increased supratentorial white matter hyperintensities volume (S-WMHV) has been reported to be a predictor of worse outcome in patients with acute ischemic stroke (AIS). However, few studies have focused on less common locations, such as brainstem white matter hyperintensities (B-WMH), and their relationship to S-WMHV. This study aimed to examine whether B-WMH affect clinical outcome after AIS or transient ischemic attack (TIA). METHODS: Based on magnetic resonance imaging evidence, B-WMH were evaluated in 313 prospectively identified patients with AIS/TIA and registered as absent or present. Standardized S-WMHV was quantified using a validated volumetric image analysis and natural log-transformed (Log_S-WMHV). Poor outcome was defined as a modified Rankin Scale score of 3-6 at 3 months after the index event. RESULTS: Brainstem white matter hyperintensities were detected in 57 (18.2%) patients. In unadjusted analyses for outcome, the presence of B-WMH was associated with worse outcome, compared with patients without B-WMH (P = 0.034). In multivariate analysis controlling for age, atrial fibrillation, stroke severity, reperfusion therapies and Log_S-WMHV, only B-WMH [odds ratio (OR), 2.46; P = 0.021] and stroke severity (OR, 1.23; P < 0.001) remained independently associated with unfavourable 90-day modified Rankin Scale score. Patients with B-WMH were older (OR, 1.06; P < 0.001) and tended to have more hyperlipidaemia (OR, 2.21; P = 0.023) and peripheral arterial disease (OR, 2.57; P = 0.031). CONCLUSIONS: Brainstem white matter hyperintensities are an independent predictor of poor outcome after AIS/TIA and this relationship persists after adjustment for important prognostic factors. Our results also show that leukoaraiosis in this location identifies patients with a specific risk factor profile, suggesting differences in the underlying pathogenesis.
Assuntos
Isquemia Encefálica/diagnóstico por imagem , Tronco Encefálico/diagnóstico por imagem , Leucoaraiose/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico por imagem , Fatores Etários , Idoso , Feminino , Humanos , Hiperlipidemias/complicações , Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/diagnóstico por imagem , Leucoaraiose/etiologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/complicações , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento , Substância Branca/diagnóstico por imagemRESUMO
BACKGROUND AND PURPOSE: Patients with acute intracerebral hemorrhage (ICH) pretreated with antithrombotic drugs may have increased early hematoma growth, which would increase mortality risk. The effect of antiplatelet (AP) and vitamin K antagonist (VKA) pretreatment on ultra-early hematoma growth (uHG) and its relationship with mortality in patients with acute supratentorial ICH was analyzed. METHODS: This is an observational retrospective study of a prospective register of 197 ICH patients with first computed tomography (CT) scan taken <6 h from ICH symptom onset. ICH volume was calculated by the ABC/2 formula and uHG by the baseline ICH volume/onset-to-CT time (ml/h) formula. The uHG analysis took into account the patient's pretreatment (none, AP or VKA) and the relationship between uHG and very-early (first 24 h) and 3-month mortality. RESULTS: In the pretreatment group, 50 (25.4%) patients were treated with AP and 37 (18.8%) with VKA. The median (interquartile range 25-75) uHG was 19.7 ml/h (2.9-44.8) for AP pretreated patients, 16.2 ml/h (5.1-42.5) for VKA pretreated patients and 8.4 ml/h (2.4-21.8) for non-pretreated patients, P = 0.019. The uHG was higher in patients with very-early [42.1 ml/h (20.1-79.6)] and total 3-month mortality [28.0 ml/h (15.8-52.5)] compared with survivors [3.9 ml/h (1.5-10.4)], P < 0.0001. Adjusted by ICH severity and previous functional status, uHG was an independent factor related to very-early (P = 0.028) and total 3-month mortality (P = 0.014). CONCLUSIONS: Patients pretreated with antithrombotics have much higher uHG, which would explain the increased mortality in these patients compared to untreated patients.
Assuntos
Anticoagulantes/uso terapêutico , Antifibrinolíticos/uso terapêutico , Encéfalo/diagnóstico por imagem , Hemorragia Cerebral/diagnóstico por imagem , Hematoma/diagnóstico por imagem , Inibidores da Agregação Plaquetária/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/farmacologia , Antifibrinolíticos/farmacologia , Encéfalo/efeitos dos fármacos , Hemorragia Cerebral/mortalidade , Feminino , Hematoma/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/farmacologia , Estudos Prospectivos , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND AND PURPOSE: Alcohol overuse (AOu) is considered an important risk factor for spontaneous intracerebral hemorrhage (ICH). The clinical and outcome characteristics of these patients (AOu-ICH) are not well known. METHODS: All patients with ICH admitted to a single university tertiary stroke center were prospectively studied from May 2005 to May 2015. Demographic profiles, radiologic characteristics and clinical outcomes of patients with acute ICH and previous AOu (>40 g/day or >300 g/week) were analyzed. RESULTS: During the study period, 555 patients with spontaneous primary ICH met the inclusion criteria. A total of 81 patients (14.6%) reported AOu (24.3% of men vs. 3.1% of women; P < 0.0001; mean age, 63 years old for AOu vs. 74 years old for non-AOu; P < 0.0001). Of the classic cardiovascular risk factors, only smoking was associated with AOu (63% vs. 12.2% of non-AOu; P < 0.0001). Initial severity and hematoma volume were similar in both groups, with no observed differences in stroke care or in-hospital medical complications. Patients with AOu had worse outcome (modified Rankin Scale score, 3-6 points) than patients without AOu at 3 months [odds ratio (OR), 2.50; 95% confidence interval (CI), 1.32-4.75; P = 0.005] and 12 months (OR, 2.47; 95% CI, 1.23-5.00; P = 0.011). A similar trend was observed at 5 years (OR, 2.48; 95% CI, 0.96-6.39; P = 0.059). CONCLUSIONS: Alcohol overuse was present in 14.6% of patients with ICH, who were predominantly male, smokers and a mean of 11 years younger than the non-AOu group. Despite a lack of differences in initial clinical severity, stroke care and early medical complications, patients with AOu had worse short- and long-term outcomes.
Assuntos
Alcoolismo/complicações , Hemorragia Cerebral/etiologia , Acidente Vascular Cerebral/etiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , FumarRESUMO
BACKGROUND AND PURPOSE: The percentage of patients with clinical total anterior circulation infarct (TACI) syndrome treated with reperfusion therapies in the absence of intracranial large-vessel occlusion (ILVO) was determined and their characteristics and outcome are described. METHODS: Data from a population-based, prospective, externally audited registry of all stroke patients treated with intravenous thrombolysis (IVT) and endovascular therapies in Catalonia from January 2011 to December 2013 were used. Patients with a baseline TACI and initial stroke severity measured by the National Institute of Health Stroke Scale (NIHSS) ≥ 8, evaluated less than 4.5 h post-onset, for whom a vascular study prior to treatment was available (n = 1070) were selected. Clinical characteristics, outcome and radiological data for patients treated with IVT alone (n = 605) were compared between those with detected ILVO (n = 474) and non-ILVO patients (n = 131). RESULTS: A total of 1070 patients met study criteria; non-ILVO was found in 131 (12.2%). Analysing the 605 patients treated only with IVT, no significant differences were found between non-ILVO and ILVO patients in age, sex, risk factors, time-to-treatment and type of radiological studies performed. Although non-ILVO patients had lower initial stroke severity (P < 0.001) and a better prognosis (P = 0.001), 51.3% had a poor outcome and 16% were deceased at 90 days. In 66.4% of patients without ILVO, a recent anterior territorial infarct was detected. CONCLUSIONS: Intracranial artery patency was observed in 12.2% of TACI patients evaluated within 4.5 h. Although absence of ILVO was associated with slightly better prognosis, more than half had a poor outcome at 3 months.
Assuntos
Arteriopatias Oclusivas/epidemiologia , Arteriopatias Oclusivas/patologia , Infarto da Artéria Cerebral Anterior/epidemiologia , Infarto da Artéria Cerebral Anterior/patologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/patologia , Idoso , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/diagnóstico por imagem , Artérias Cerebrais/patologia , Procedimentos Endovasculares , Feminino , Humanos , Infarto da Artéria Cerebral Anterior/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Espanha/epidemiologia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: The objective of our study was to evaluate sex differences in the impact of weight and abdominal obesity on the risk of ischemic stroke. METHODS: We included 388 patients with ischemic stroke (aged <75 years) assessed consecutively in our hospital and 732 controls matched by age and sex. Vascular risk factors and anthropometric data (waist circumference, weight and height) were recorded. The impact of three anthropometric variables [body mass index (BMI), waist circumference and waist to height ratio] on ischemic stroke risk was calculated. These variables were divided into quartiles for a comprehensive comparison between cases and controls, stratified by sex and adjusted in logistic regression by age and vascular risk factors. Further logistic regression using dummy variables was performed to evaluate the association between BMI-adjusted abdominal obesity and stroke risk. RESULTS: Increased BMI was not associated with increased stroke risk overall or in women, but was a protective factor in men [P = 0.03; odds ratio (OR), 0.59 (0.37-0.94)]. Abdominal obesity was a risk factor for stroke in women, in both waist circumference [P < 0.001; OR, 5.79 (3.10-10.85)] and waist to height ratio [P < 0.001; OR, 3.61 (1.99-6.54)] analyses, but was not significant in men. When considered independently of BMI, abdominal obesity was a risk factor in both sexes, but the strength of the association was significantly higher in women. CONCLUSIONS: Increased BMI was related to a lower risk of stroke in men. Abdominal obesity was associated with ischemic stroke in women. The impact of abdominal obesity on stroke risk differs by sex.
Assuntos
Isquemia Encefálica/epidemiologia , Obesidade Abdominal/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Antropometria , Estatura , Índice de Massa Corporal , Isquemia Encefálica/etiologia , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade Abdominal/complicações , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Acidente Vascular Cerebral/etiologia , Circunferência da Cintura , Adulto JovemRESUMO
This article provides an overview of stroke genetics studies ranging from the candidate gene approach to more recent studies by the genome wide association. It highlights the complexity of stroke owing to its different aetiopathogenic mechanisms, the difficulties in studying its genetic component, and the solutions provided to date. The study emphasises the importance of cooperation between the different centres, whether this takes places occasionally or through the creation of lasting consortiums. This strategy is currently essential to the completion of high-quality scientific studies that allow researchers to gain a better knowledge of the genetic component of stroke as it relates to aetiology, treatment, and prevention.
Assuntos
Predisposição Genética para Doença , Acidente Vascular Cerebral/genética , Epigênese Genética , Estudo de Associação Genômica Ampla , Humanos , Polimorfismo de Nucleotídeo Único , Fatores de RiscoRESUMO
BACKGROUND AND PURPOSE: In patients with atrial fibrillation (AF), stroke risk stratification schemes have been developed to optimize antithrombotic treatment. The CHADS(2) score is frequently used but has limitations. The CHA(2) DS(2) -VASc score improves risk prediction. Our objectives are to describe CHADS(2) and CHA(2) DS(2) -VASc score distribution in a cohort of patients with AF and first-ever ischaemic stroke (FIS) and to identify differences in embolic risk stratification. METHODS: Our cohort included 589 patients with FIS, previous modified Rankin score ≤ 3, and non-valvular AF. We recorded demographic data, vascular risk factors, and antithrombotic pre-treatment. The CHADS(2) and CHA(2) DS(2) -VASc scores were calculated according to clinical status before stroke onset. RESULTS: In 186 (31.6%) patients, AF was previously unknown. Of patients with known AF and CHADS(2) ≥ 2 (n=320), only 103 (32.2%) were taking anticoagulants; more than half of these patients had an INR <2. The CHADS(2) score placed 142 (24.1%) patients in the low-intermediate risk (score ≤ 1) category compared with 21 (3.6%) with CHA(2) DS(2) -VASc, P < 0.001. Applying CHA(2) DS(2) -VASc reclassified 121 (85.2%) subjects in the CHADS(2) low-intermediate risk category as high risk (≥ 2), an indication for anticoagulants. Of the 21 patients who suffered a stroke despite their low CHA(2) DS(2) -VASc score (≤ 1), seven (33.3%) reported alcohol overuse, and six (28.5%) had a concomitant stroke etiology. CONCLUSIONS: About 25% of FIS patients with AF had a CHADS(2) score ≤ 1. Despite the high CHADS(2) score of our population, few patients received the recommended antithrombotic treatment according to their thromboembolic risk. Using the CHA(2) DS(2) -VASc schema significantly increased the percentage of patients indicated for anticoagulation.
Assuntos
Fibrilação Atrial/complicações , Acidente Vascular Cerebral/complicações , Idoso , Idoso de 80 Anos ou mais , Alcoolismo/complicações , Alcoolismo/epidemiologia , Fibrilação Atrial/epidemiologia , Isquemia Encefálica/complicações , Cardiomiopatia Dilatada/complicações , Cardiomiopatia Dilatada/epidemiologia , Estudos de Coortes , Eletrocardiografia , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/epidemiologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/epidemiologia , Tromboembolia/epidemiologia , Doenças Vasculares/complicações , Doenças Vasculares/epidemiologiaRESUMO
While TIA patients have transient symptoms, they should not be underestimated, as they could have an underlying pathology that may lead to a subsequent stroke: stroke recurrence (SR). Previously, it has been described the involvement of lipids in different vascular diseases. The aim of the current study was to perform a lipidomic analysis to identify differences in the lipidomic profile between patients with SR and patients without. Untargeted lipidomic analysis was performed in plasma samples of 460 consecutive TIA patients recruited < 24 h after the onset of symptoms. 37 (8%) patients suffered SR at 90 days. Lipidomic profiling disclosed 7 lipid species differentially expressed between groups: 5 triacylglycerides (TG), 1 diacylglyceride (DG), and 1 alkenyl-PE (plasmalogen) [specifically, TG(56:1), TG(63:0), TG(58:2), TG(50:5), TG(53:7, DG(38:5)) and PE(P-18:0/18:2)]. 6 of these 7 lipid species belonged to the glycerolipid family and a plasmalogen, pointing to bioenergetics pathways, as well as oxidative stress response. In this context, it was proposed the PE(P-18:0/18:2) as potential biomarker of SR condition.The observed changes in lipid patterns suggest pathophysiological mechanisms associated with lipid droplets metabolism and antioxidant protection that is translated to plasma level as consequence of a more intensive or high-risk ischemic condition related to SR.
Assuntos
Lipidômica , Lipídeos , Recidiva , Acidente Vascular Cerebral , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Acidente Vascular Cerebral/metabolismo , Seguimentos , Lipídeos/análiseRESUMO
BACKGROUND: According to the reverse epidemiology hypothesis, high cholesterol levels might be protective and associated with greater survival rates under certain conditions. In stroke patients, a clear correlation between lipid levels and mortality after ischaemic and hemorrhagic strokes has been demonstrated. The aim of this study was to analyze the impact of lipid levels on 3-month mortality in patients with ischaemic stroke (IS) homogeneously treated with intravenous rtPA and admitted to a monitored acute stroke unit. METHODS: Retrospective analysis of a prospective cohort of 220 patients with an IS treated with rtPA within the first 4.5 h in a single tertiary hospital from January 2005 to August 2010. RESULTS: Mortality at 3 months was 15.0%. Univariate analysis showed that age, NIHSS at admission, heart failure, and atrial fibrillation were directly related to 3-month mortality; cholesterol, triglycerides, and low density lipoprotein were inversely associated. The death rate by cholesterol level was 5.5% for the highest tertile (>192 mg/dl), 13.7% for the middle (192-155 mg/dl), and 25.7% for the lowest (<155 mg/dl), P = 0.003. Multivariate analysis showed that amongst the lipid determinations, only cholesterol [OR: 0.985 (95% CI: 0.972-0.998), P = 0.021] was inversely associated with 3-month mortality. The 'protective' effect of cholesterol was independent of stroke severity and remained significant in non-lacunar strokes. CONCLUSIONS: Survival of stroke patients receiving current, most effective medical treatment is related to blood cholesterol levels, with an inverse relationship between cholesterol and mortality. The mechanism of this apparently paradoxical situation remains unexplained but merits further research.
Assuntos
Colesterol/sangue , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Glicemia/metabolismo , Hemorragia Cerebral/sangue , Hemorragia Cerebral/etiologia , Estudos de Coortes , Análise Fatorial , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/mortalidade , Fatores de TempoRESUMO
BACKGROUND: Statins treatment may have potential clinical impact in vascular disease beyond cholesterol lowering. Its benefits have been documented in cerebral ischaemia and in subarachnoid haemorrhage. In intracerebral haemorrhage (ICH), experimental models in statin-treated animals have better outcome than non-treated ones, but in humans the relationship is unclear. We investigated whether patients treated with statins before the onset of intracerebral haemorrhage have a better outcome at 3 months than patients without statins pre-treatment. METHODS: Retrospective review of primary intracerebral haemorrhage case series from a prospective stroke register. We recorded demographics, vascular risk factors, previous statin treatment, Glasgow coma scale (GCS) at onset, ICH scale, hematoma volume and location, ventricular extension of the hematoma, and functional outcome at 3 months. The effect of prior statin treatment on good outcome (modified Rankin scale [mRS] 0 to 2) was analysed by logistic regression analysis. RESULTS: We included 269 patients (age 71.9 +/- 12.4, mean +/- SD, 152 males). Thirty-four patients (12.6%) were on prior statin treatment when admitted. There were no differences in fasting serum cholesterol and triglycerides levels between the statin pre-treated groups and the group without statin pre-treatment. Multivariate regression analysis showed a significant association between age (OR: 0.95; CI 0.92-0.97), ICH volume (OR: 0.96; CI 0.94-0.98), GCS (OR: 1.55; CI 1.21-1.98), pre-treatment with statins (OR: 4.21; CI 1.47-12.17; P = 0.008), and good outcome at 3 months. CONCLUSIONS: Statins pre-treatment of patients with intracerebral haemorrhage may provide better functional outcome at 3 months of acute onset.
Assuntos
Hemorragia Cerebral/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Fatores Etários , Idoso , Encéfalo/efeitos dos fármacos , Encéfalo/patologia , Hemorragia Cerebral/metabolismo , Hemorragia Cerebral/patologia , Feminino , Hematoma/tratamento farmacológico , Hematoma/patologia , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Modelos Logísticos , Masculino , Análise Multivariada , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Índice de Gravidade de Doença , Acidente Vascular Cerebral/tratamento farmacológico , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Most of the models to predict prognosis after an ischemic stroke include complex mathematical equations or too many variables, making them difficult to use in the daily clinic. We want to predict disability 3 months after an ischemic stroke in an independent patient not receiving recanalization treatment within the first 24 h, using a minimum set of variables and an easy tool to facilitate its implementation. As a secondary aim, we calculated the capacity of the score to predict an excellent/devastating outcome and mortality. METHODS: Eight hundred and forty-four patients were evaluated. A multivariable ordinal logistic regression was used to obtain the score. The Modified Rankin Scale (mRS) was used to estimate disability at the third month. The results were replicated in another independent cohort (378 patients). The "polr" function of R was used to perform the regression, stratifying the sample into seven groups with different cutoffs (from mRS 0 to 6). RESULTS: The Parsifal score was generated with: age, previous mRS, initial NIHSS, glycemia on admission, and dyslipidemia. This score predicts disability with an accuracy of 80-76% (discovery-replication cohorts). It has an AUC of 0.86 in the discovery and replication cohort. The specificity was 90-80% (discovery-replication cohorts); while, the sensitivity was 64-74% (discovery-replication cohorts). The prediction of an excellent or devastating outcome, as well as mortality, obtained good discrimination with AUC > 0.80. CONCLUSIONS: The Parsifal Score is a model that predicts disability at the third month, with only five variables, with good discrimination and calibration, and being replicated in an independent cohort.
Assuntos
Isquemia Encefálica , Pessoas com Deficiência , AVC Isquêmico , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Avaliação da Deficiência , Humanos , AVC Isquêmico/complicações , Prognóstico , Resultado do TratamentoRESUMO
BACKGROUND: In the hypertensive small vessel disease (HSVD), it remains unclear why some patients develop lacunar infarcts (LIs) whilst others develop deep intracerebral hemorrhages (dICHs). Inflammation might be related to LI, and leukocyte and monocyte counts are regarded as an inflammatory marker of ischemic stroke. OBJECTIVE: We investigated the relationship between leukocyte and monocyte counts determined in the first 24 h after stroke onset in HSVD patients. METHODS: We prospectively studied 236 patients with first acute stroke because of HSVD (129 LI and 107 dICH). We analyzed demographic data, vascular risk factors, and white blood cell count subtypes obtained in the first 24 h after stroke. RESULTS: The multivariate analysis showed that LI subtype of HSVD was correlated with hyperlipidemia (P < 0.0001), a higher monocyte count (P = 0.002), and showed a trend with current smoking (P = 0.051), whereas dICH subtype was correlated with low serum total cholesterol (P = 0.003), low serum triglycerides (P < 0.0001), and high neutrophil count (P = 0.050). CONCLUSIONS: In patients who developed HSVD-related stroke, high monocyte count, current smoking, and hyperlipidemia are prothrombotic factors related to LI, whereas low cholesterol and triglyceride values are related to dICH. Monocyte count might be an inflammatory risk marker for the occlusion of small vessels in hypertensive patients.
Assuntos
Hemorragia Cerebral/etiologia , Hipertensão/complicações , Doenças Arteriais Intracranianas/complicações , Monócitos , Acidente Vascular Cerebral/etiologia , Idoso , Biomarcadores/sangue , Vasos Sanguíneos/patologia , Feminino , Humanos , Hipertensão/sangue , Hipertensão/patologia , Doenças Arteriais Intracranianas/sangue , Doenças Arteriais Intracranianas/patologia , Contagem de Leucócitos , MasculinoRESUMO
BACKGROUND: The conclusions of previous studies show little agreement concerning the relationship between weather and the incidence of stroke. We analyse the relationship between daily meteorological conditions and daily as well as seasonal stroke incidence. METHODS: 1,286 consecutive strokes assessed during 3 years (2001-2003) from the reference area of Hospital del Mar were classified as intracerebral haemorrhage (ICH) (n = 243) or ischaemic stroke (IS) (n = 1,043). IS was divided in non-lacunar stroke (NLS) (n = 732) and lacunar stroke (LS) (n = 311). Daily meteorological data were obtained from 'Observatori Fabra' of Barcelona: atmospheric pressure (AP), relative humidity, maximum, minimum, and mean temperatures, and the variation of all these measures compared with the previous day. RESULTS: Total stroke (TS) incidence showed little association with AP (coefficient of confidence, CC: -0.072; p = 0.022), but was higher with the AP variations (CC: 0.127; p < 0.001). NLS were related to AP falls (OR: 2.41; p < 0.001) whilst ICHs were associated with AP rises (OR: 2.07; p = 0.01). NLS and temperature showed an inverse correlation; however, it lost its significance after adjusting for AP variations. The daily incidences of NLS and ICH were higher in autumn and in winter, but depended strongly on the daily variations of AP. No other associations were found. CONCLUSIONS: The incidences of NLS and ICH are related to AP changes compared with the previous day. AP changes largely explain the seasonal and daily variations in the incidence of stroke. These data may help to explain the controversy in previous studies and to promote studies focused on the trigger mechanisms of stroke.
Assuntos
Isquemia Encefálica/epidemiologia , Hemorragias Intracranianas/epidemiologia , Estações do Ano , Acidente Vascular Cerebral/epidemiologia , Tempo (Meteorologia) , Humanos , Incidência , Modelos Logísticos , Espanha/epidemiologia , População Urbana/estatística & dados numéricosRESUMO
OBJECTIVE: to evaluate the influence of clustering of vascular risk factors (VRF) on in-hospital mortality in patients with acute ischemic stroke (AIS) developing a risk score for mortality prediction. METHODS: clinical data from 1527 patients admitted to hospital with a first-ever AIS were prospectively evaluated from 1997 to 2005 assessing the presence of six VRF: diabetes, hypertension, hyperlipidemia, ischemic heart disease, atrial fibrillation and peripheral arterial disease. A composite vascular risk score (VRS) was created using five risk factors. Hyperlipidemia was excluded from the score due to its protective impact on mortality. Two modified VRS models were created and assessed for their accuracy as predictors for in-hospital mortality based on the odds ratio for each VRF obtained in the univariate analysis. RESULTS: 197 patients (12.9 %) died during the acute hospitalization period. Stroke severity increased with each additional VRF (p = 0.002). Cox proportional hazards model adjusted for confounders showed an association between the composite VRS and in-hospital mortality (p = 0.045). According to the clustering of VRS, the risk for in-hospital death increased from 1.951 (95 % CI 1.041-3.665) for patients having one VRS to 2.343 (95% CI 1.081-5.076) for those having a VRS > or = 4. ROC curves showed that the modified VRS model based on a given value of one for each accumulated VRF, including the absence of hyperlipidemia, had the highest predictive capability for in-hospital mortality (p < 0.0001). CONCLUSIONS: the presence of multiple VRF in patients with acute ischemic stroke increases the stroke severity and the risk of in-hospital death.
Assuntos
Mortalidade Hospitalar , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Isquemia Encefálica/complicações , Análise por Conglomerados , Diabetes Mellitus , Progressão da Doença , Feminino , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Prospectivos , Curva ROC , Estudos Retrospectivos , Fatores de RiscoRESUMO
Brain ischemic lesions identified by diffusion-weighted imaging (DWI) have been shown to predict high risk of early future ischemic events in patients with transient ischemic attacks and minor stroke. The aim of this study is to analyze different brain MRI-DWI patterns in patients with mild-moderate stroke to define acute patterns related with a higher risk of stroke recurrence in long-term follow-up (from 6 to 36 months). Retrospective review of case series from a prospective stroke record including 253 patients with mild-moderate stroke (NIHSS from 1 to 7) and acute MRI-DWI lesions. MRI-DWI lesions were analyzed to determine clinically relevant lesions, based on the number, location, age and affected arterial territories. We defined three patterns: (1) multiple versus single lesions; (2) single deep versus single cortical lesions; and (3) single lesions versus multiple lesions affecting different arterial territories and/or of different age. The impact of these patterns on recurrence was analyzed by Cox regression analysis. 38 patients (15.0%) suffered a recurrence. Univariate analysis showed the risk of recurrence for each pattern. Pattern 1: patients with multiple lesions had greater risk of recurrence than those with single lesions (28.2 vs. 9.9%; OR: 3.75 (95% CI: 1.76-7.27), p < 0.0001). Pattern 2: patients with single cortical lesions had higher risk than those with deep lesions (14.3 vs. 6.7% OR: 2.33 (95% CI: 0.86-6.33), p < 0.089). Pattern 3: patients with multiple DWI in different territories or different age had the highest recurrence rate (30.6%), OR: 4.01 (95% CI: 1.70-9.47), p < 0.001, compared to patients with single lesions. Cox regression analysis adjusted by possible confounders, showed that for pattern 1 the OR for recurrence was 2.49 (95% CI: 1.27-4.89), p = 0.008; for pattern 2, OR:1.99 (95% CI: 0.74-5.37), p = 0.17; for pattern 3, OR: 2.85 (95% CI: 1.31-6.15), p = 0.008. Brain MRI-DWI patterns assessed in the acute phase of mild-moderate stroke are useful to identify those patients at high risk of recurrence.
Assuntos
Encéfalo/patologia , Acidente Vascular Cerebral/patologia , Doença Aguda , Idoso , Artérias Cerebrais/patologia , Imagem de Difusão por Ressonância Magnética , Feminino , Seguimentos , Humanos , Masculino , Modelos de Riscos Proporcionais , Estudos Prospectivos , Recidiva , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Análise de SobrevidaRESUMO
Post-stroke levels of total cholesterol (TC) appear to be negatively associated with stroke mortality. Statin pretreatment might affect this association. Sex differences in the prognostic value of the lipid profile have not yet been studied. We have evaluated the impact of TC, high- and low-density lipoprotein (HDL and LDL, respectively), and triglyceride (TG) levels on the 3-month outcome after a first ischemic stroke (IS) according to sex and previous statin use. The study group consisted of a hospital-based cohort of consecutive patients with a diagnosis of first IS. Poor outcome was defined as a modified Rankin Scale (mRS) score >or=3 at 90 days. The odds ration (OR) for poor prognosis was analyzed for each sex using logistic regression models adjusted for vascular risk factors and statin pretreatment. A total of 591 patients were included in the analysis (318 men). The predictors of a 90-day poor outcome were age and initial NIH Stroke Scale (NIHSS) score in women, and age, initial NIHSS, smoking, atrial fibrillation, and thrombolytic treatment in men. In women, none of the lipids studied affected the 90-day prognosis. Men falling in the last quintile of TC [OR: 0.68 95% confidence interval (95% CI) 0.52-0.88; p = 0.004] and LDL (OR 0.74, 95% CI 0.56-0.98; p = 0.04) have better outcome than men in the first quintile. Adjusting for statin pretreatment did not change the results. The results indicated that an association between poststroke lipids and prognosis may vary by sex. In women, lipids were not associated with the outcome; in men, lower TC and LDL were associated with worse prognosis. These differences can not be explained by statin use and require further research.
Assuntos
Isquemia Encefálica/sangue , Lipoproteínas HDL/sangue , Lipoproteínas LDL/sangue , Caracteres Sexuais , Acidente Vascular Cerebral/sangue , Triglicerídeos/sangue , Idoso , Análise de Variância , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/tratamento farmacológico , Estudos de Coortes , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Modelos Logísticos , Masculino , Razão de Chances , Prognóstico , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/tratamento farmacológico , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate clinical and manometric characteristics of multiple sclerosis (MS) patients with anorectal dysfunction (ARD) and their influence on biofeedback outcome. PATIENTS AND METHODS: Patients were clinically and manometrically studied and compared with controls. Patients were subsequently offered to initiate biofeedback manoeuvres to improve ARD. RESULTS: Fifty-two patients with ARD, 39 women, mean age 44.96 +/- 9.26 years, mean Expanded Disability Status Scale 4.13 +/- 1.72, were evaluated. Thirty-one patients had relapsing-remitting (RR), 16 secondary progressive and five primary progressive MS. ARD complaints were constipation (67.3%), double ARD (23.1%) and isolated incontinence (9.6%). The manometric study showed significant differences in patients compared with controls in maximal contraction pressures (98.1 +/- 44.2 mm Hg versus 152.05 +/- 66.9 mm Hg, P < 0.001) and anal inhibitory reflex threshold (92.9 +/- 63.4 mL versus 40.45 +/- 11.3 mL, P < 0.001). Maximal pressure was lower in progressive forms compared with RR forms (83.1 +/- 36.2 mm Hg versus 108.2 +/- 46.7 mm Hg, P < 0.05) in relation to higher disability. Patients with paradoxical contraction (PC) (35 patients, 67.3%) showed more manometric disturbances. From a total of 18 patients performing biofeedback, those reporting some improvement (six complete, two partial) had milder manometric abnormalities. CONCLUSIONS: The most frequent manometric abnormalities in our MS patients with ARD were alterations of maximal pressures, anal inhibitory reflex and PC. Biofeedback could be more useful in patients with lower disability and manometric alterations.
Assuntos
Biorretroalimentação Psicológica , Manometria , Esclerose Múltipla/complicações , Doenças Retais/fisiopatologia , Doenças Retais/terapia , Adulto , Constipação Intestinal/etiologia , Constipação Intestinal/fisiopatologia , Constipação Intestinal/terapia , Defecação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibição Neural , Pressão , Doenças Retais/etiologia , Reto/inervação , Reto/fisiologia , ReflexoRESUMO
OBJECTIVE: To ascertain the prevalence of anorectal dysfunction (ARD) in patients with multiple sclerosis (MS) and its relationship with MS clinical characteristics. METHODS: Prospective transversal study in 193 patients with MS. All patients fulfilled a protocol that included: demographic variables, clinical characteristics of MS and the presence of ARD and urinary dysfunction (UD). RESULTS: One hundred and ninety-three patients: 66.8% women, an average age of 42.8 (12.1) years; 67.8% of patients had relapsing remitting MS, 21.2% a secondary progressive and 10.9% a primary progressive form. The average duration of MS was 10.7 (9.4) years and the EDSS 2.8 (2.3). ARD was present in 93 patients (48.2%), and UD in 50.2%. ARD associated to UD was present in 35.7% of cases. The univariate study revealed that patients with ARD were older (P <0.001), had greater disability (P <0.0001), longer disease duration (P <0.001) and a greater association with UD (P<0.0001). ARD was more frequent in progressive forms (P<0.0001). The logistic regression analysis showed that female sex (P = 0.015), EDSS (P = 0.002) and UD (P = 0.003) were independent factors related to ARD. CONCLUSION: ARD is a highly prevalent disorder in MS. Female sex, EDSS and UD are independent predictors of ARD development.
Assuntos
Canal Anal/fisiopatologia , Esclerose Múltipla/fisiopatologia , Reto/fisiopatologia , Adulto , Fatores Etários , Idade de Início , Análise de Variância , Pessoas com Deficiência , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/epidemiologia , Análise Multivariada , Prevalência , Estudos ProspectivosRESUMO
OBJECTIVE: To test the hypothesis that low serum cholesterol and low serum triglyceride levels at admission are related to an increase of in-hospital mortality in patients with first-ever supratentorial spontaneous intracerebral hemorrhage (ICH). METHODS: The authors obtained the serum cholesterol and triglyceride levels during the first 48 hours after first-ever ICH in 184 patients. They analyzed the impact of serum cholesterol and triglyceride concentrations on the in-hospital mortality after adjustment for possible confounding variables according to the results of the univariate analysis (age, hemorrhage volume, intraventricular extension, glycemia, serum albumin, and Glasgow Coma Scale score at admission) using the Cox proportional hazards model. They also analyzed the survival curves according to the cholesterol and triglyceride quartiles. RESULTS: Low serum cholesterol (p = 0.002; hazard ratio [HR] 0.988 [95% CI 0.979 to 0.997] mg/dL) and low serum triglyceride (p = 0.011; HR 0.986 [95% CI 0.976 to 0.997] mg/dL) concentrations were independently associated with increased in-hospital mortality after ICH. Analyzed by quartiles, the HR of in-hospital mortality was 3.136 (95% CI 0.833 to 11.087) for patients in the lowest cholesterol quartile (< 166 mg/dL) and 3.484 (95% CI 1.088 to 11.155) for patients in the lowest triglyceride quartile (< 74 mg/dL). CONCLUSIONS: Low serum cholesterol and triglyceride levels obtained during the first hours after intracerebral hemorrhage (ICH) are strong independent predictors of in-hospital mortality in patients with spontaneous supratentorial ICH.