Abstract Background Evidence shows possible benefits from continuous drainage by lumbar drain after aneurysmal subarachnoid hemorrhage (SAH). Under the hypothesis that compartmentalization occurs ...between the ventricle and subarachnoid space after massive SAH, this study aimed to evaluate the biochemical differences between ventricular and intrathecal cerebrospinal fluid (CSF) and assess the role of CSF lactate in shunt-dependent hydrocephalus (SDHC) after aneurysmal SAH. Materials and methods Patients with modified Fisher grade III/IV aneurysmal SAH who underwent early obliteration were evaluated. Intrathecal and intraventricular CSF were obtained on day 7 post-SAH to measure their biochemical composition in terms of total protein, glucose, ferritin, and lactate. The associations of SDHC with the clinical parameters and CSF data were analyzed. Results There were 28 patients (mean age, 55.4 y; males, 46.6%), including 18 (64.3%) with SDHC. Intrathecal CSF had significantly higher levels of total protein, ferritin, hemoglobin, and lactate but lower glucose level than intraventricular CSF (all P < 0.0001). By multivariate analysis of clinical and CSF parameters, elevated intrathecal CSF lactate ( P = 0.036) and the presence of intraventricular hemorrhage ( P = 0.05) were independent factors associated with SDHC. Moreover, intrathecal lactate >5.5 μM effectively predicted the occurrence of SDHC (odds ratio: 32, 95% confidence interval: 3.8–270.8; P = 0.0015). Conclusions By compartmentalization of the subarachnoid space after SAH, intrathecal lactate level is a useful predictive parameter for long-term SDHC in patients with aneurysmal SAH patients.
Background Impaired dynamic cerebral autoregulation (DCA) has been shown in patients with severe (≥70%) internal carotid artery (ICA) stenosis, but DCA in moderate (50% to 69%) ICA stenosis, ...especially its response to carotid revascularization, has rarely been reported. Our study aimed to characterize DCA in severe and moderate ICA stenosis before and after carotid stenting. Methods This study included 21 patients with ICA stenosis ≥50% who received carotid stenting. Data of arterial blood pressure and cerebral blood flow velocity of the middle cerebral artery, measured by transcranial Doppler, were collected for 10 minutes ≤24 hours before and after stenting. The DCA index, represented as aMx, was assessed by calculating the Pearson product-moment correlation coefficient of spontaneous arterial blood pressure and cerebral blood flow velocity fluctuations. The relationship between aMx and stenotic severity and also alternations of aMx before and after stenting were assessed. Results Carotid stenting was effective to improve the DCA in the stenting side but not in the contralateral nonstenting side. In considering individual ICAs, the average aMx (mean ± SD) increased significantly from ICA stenosis <50% (0.117 ± 0.091) to 50% to 69% (0.349 ± 0.144), 70% to 99% (0.456 ± 0.147), and total occlusion (0.557 ± 0.210; P < .05, P < .01, and P < .01, compared with 50% to 69%, 70% to 99%, or total occlusion with <50% stenosis). The correlation between the degree of ICA stenosis and the aMx was also significant ( r = 0.693, P < .005). The aMx improved significantly in the stented side after carotid stenting in both moderate and severe ICA stenosis, and this finding was not affected by age, sex, risk factors, or clinical symptoms. Conclusions In addition to patients with severe carotid stenosis, patients with moderate carotid stenosis may also have impaired DCA that can be restored after carotid stenting.
Abstract Chiu H-T, Wang Y-H, Jeng J-S, Chen B-B, Pan S-L. Effect of functional status on survival in patients with stroke: is independent ambulation a key determinant? Objective To investigate the ...effect of functional status, measured using the Modified Rankin Scale (MRS), at 3 months after stroke on survival in patients with stroke. Design Cohort study. Setting Referral medical center. Participants Patients with stroke (N=1032). Interventions Not applicable. Main Outcome Measure Survival after stroke. Results The Kaplan-Meier survival curves stratified by the 3-month MRS score showed 2 clear groups of patients with 3-month MRS scores of 0 to 3 (able to walk without assistance) and 4 or 5 (unable to walk without assistance). Accordingly, we grouped the patients into a high function (HF) group (3-month MRS≦3) and a low function (LF) group (3-month MRS≧4). Multiple Cox regression analysis showed that the LF group had significantly poorer survival (adjusted hazard ratio=4.69; 95% confidence interval CI, 2.89–7.60; P <.001) than the HF group. Other significant risk factors of higher mortality were older age, history of diabetes mellitus, and heart disease. Conclusions This study showed a significant influence of the 3-month MRS score on stroke survival. Moreover, independent ambulation may be a major determinant of a favorable survival prognosis. This finding suggests a potential role of rehabilitation in promoting stroke survival by maximizing ambulation function.
Abstract Purposes The aim of this study was to investigate the factors associated with use of emergency medical services (EMS) in patients with acute stroke. Methods Prospective data on consecutive ...patients with acute stroke who presented to the emergency department of a university medical center from January 1, 2010, to July 31, 2011, were analyzed. Patients were excluded if they had an unknown residence, had onset of stroke at a nursing home or hospital, or were transferred from another hospital. Variables for all patients with stroke and ischemic stroke who did and did not use EMS were compared. Results In total, 1344 patients (60% male; mean age, 68.7 years) were included. Use of EMS (n = 409; 30.4%) was significantly associated with a higher level of education (≧ 6 years vs < 6 years; odds ratio OR, 1.69; 95% confidence interval CI, 1.25-2.29), a higher National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.05-1.11), altered consciousness (OR, 1.88; 95% CI, 1.25-2.84), and atrial fibrillation (OR, 2.43; 95% CI, 1.71-3.44) after adjustment. For patients with ischemic stroke, use of EMS was significantly higher in cases of cardioembolism (OR, 3.04; 95% CI, 1.40-6.60) and large artery atherothrombosis (OR, 2.10; 95% CI, 1.22-3.62) than lacunar infarction. Conclusion Patients with stroke who have altered consciousness, a higher level of education, a higher National Institutes of Health Stroke Scale score, atrial fibrillation, and cardioembolic stroke were more likely to use EMS.
Abstract Hsueh I-P, Jeng J-S, Lee Y, Sheu C-F, Hsieh C-L. Construct validity of the Stroke-Specific Quality of Life questionnaire in ischemic stroke patients. Objectives To investigate the construct ...validity of the commonly used 8- and 12-domain versions of the Stroke-Specific Quality of Life (SS-QOL) with a first-order factor model. The better-fitted version was further evaluated by a second-order factor structure model in order to determine whether a summary score is justified. Design Cohort study. Setting Outpatient stroke clinic. Participants Patients (N=388) with ischemic stroke. Intervention Not applicable. Main Outcome Measures The SS-QOL. We first conducted confirmatory factor analysis (CFA) to evaluate the construct validity of the first-order 8- or 12-domain versions of the SS-QOL. The better-fitted version was then validated by investigating the second-order health-related quality of life (HRQOL) factor. Results The 12-domain version, but not the 8-domain version, had sufficient goodness of fit (χ2 =2041.7, df =1061, χ2 / df =1.9, comparative fit index CFI=0.98, Tucker-Lewis index TLI=0.98, and root mean square error of approximation=0.05). All items of the 12-domain version showed acceptable factor loadings (>0.40) and were retained. Furthermore, the second-order CFA fit indices of the 12 domains were acceptable (χ2 =2630.3, df =1115, χ2 / df =2.4, CFI=0.97, TLI=0.97, root mean square error of approximation=0.06), indicating that a summary score was justified for representing the overall status of HRQOL. Conclusions Our results show that the construct validity of the 12-domain SS-QOL is well supported for measuring HRQOL in ischemic stroke patients. Thus, we recommend the 12-domain version of the SS-QOL for use in capturing the multiple impacts of stroke as well as overall HRQOL status on the basis of patients' perspectives.
Background Large anterior choroidal artery (AChA) infarcts are frequently associated with stroke evolution. This study aimed to investigate the major determinants for stroke evolution in patients ...with large AChA infarcts. Methods We studied 118 consecutive adult patients with acute large AChA infarcts. The diagnosis was confirmed as abnormal hyperintensities in 3 or more rostracaudal magnetic resonance imaging slices (5 mm thickness) using diffusion-weighted imaging within typical AChA vascular regions. Stroke evolution was defined as neurologic deterioration with an increase in National Institutes of Health Stroke Scale (NIHSS) score by at least 4 or an increase of NIHSS score in motor function by at least 2 in 7 days after stroke onset. Results Forty-seven (39.8%) patients developed stroke evolution. Thrombolytic therapy was inversely associated with the occurrence of stroke evolution ( P = .004). Using multivariate analysis, thrombolytic therapy was the only protective determinant for stroke evolution (adjusted odds ratio, .08; 95% confidence interval, .01 to .67). Patients with large AChA infarcts receiving thrombolytic therapy had less unfavorable long-term functional outcome than those not receiving thrombolytic therapy (adjusted odds ratio, .11; 95% confidence interval, .02-.75). Conclusions Thrombolytic therapy is an only determinant factor for stroke evolution in large AChA infarcts, which reduced the risk of stroke evolution and improved functional outcome.
Objective Rarely has childhood stroke been compared with adult stroke for incidence or cost. This population study compared the stroke incidence and the associated hospitalization care costs between ...children and adults in Taiwan. Study design We used reimbursement claims data from the National Health Insurance program to identify stroke diagnoses in 1997 to 2003. The inpatient costs of both the first admission and recurrent stroke from 1979 childhood cases and 365,169 adult cases were compared by age and stroke subtype, excluding those less than 1 month of age. Results The mean inpatient costs were higher for patients <10 and 10 to 19 years of age ($3565 per case) compared with adult cases ($1933), including both first and recurrent hospitalizations, and they were higher for the recurrent cases. Patients <10 years old had the highest proportional incidence of hemorrhage events (71.4%), followed by patients in the 10- to 19-year-old group (61.4%), and the lowest for adults (21.3%). Hemorrhagic events incurred 2 to 12 times higher cost than other types of stroke. Conclusions The hospitalization care costs for stroke are higher for children than for adults because of a greater proportion of hemorrhagic cases among children.
A 45-year-old man receiving warfarin treatment suffered from an intracerebral hemorrhage. Four-factor prothrombin complex concentrate (PCC) was administered to correct coagulopathy. However, ...bilateral renal infarcts and a cerebral infarct developed on day 5 and 7, respectively after PCC administration. Although the occurrence of PCC-related thromboembolism is low, health care practitioners should closely follow-up the symptoms and signs of thrombosis after PCC administration.
Abstract Background Arterial dissection involving cervicocranial arteries usually results in ischemia or SAH. This study correlated the clinical manifestations, image characteristics, and outcome of ...arterial dissection and compared the differences between arterial dissection of anterior and posterior circulation at our institute. Methods Clinical symptoms and neuroradiologic findings were retrospectively analyzed in 73 patients (6-75 years old) who had a spontaneous arterial dissection of cervicocranial vessels verified by angiography or MRI. Twenty-four cases of ACAD and 49 cases of PCAD were included in this study. Results The leading presentation of arterial dissection of ACAD group was ischemic stroke (79.2%), and that of posterior circulation was SAH (44.9%), followed by ischemic stroke (42.8%). In the ACAD group, the extracranial ICA was more commonly involved (62.5%), with long segmental narrowing the most common angiographic finding. In the PCAD group, the intracranial VA was more commonly involved (81.6%), with alternating narrowing and dilatation the leading angiographic picture. All the cases presenting with ischemic stroke or headache were conservatively treated with anticoagulants or antiplatelets, except for one treated with intra-arterial thrombolysis for thromboembolism in basilar artery at an early stage. One of them died of progressed brainstem infarct in spite of anticoagulation therapy. All the others reached improved or stable clinical condition. Eighteen cases were treated by surgical or endovascular intervention. None of them had rebleeding. Of the 5 patients with SAH due to dissecting lumens without treatment, 2 died of rebleeding. Conclusions Ischemia is the predominant presentation of ACAD; and PCAD has similar occurrence of SAH and ischemia. Intracranial arterial dissection is not uncommon; and it should be kept in the list of differential diagnosis of young stroke. Aggressive treatment of arterial dissection presenting with SAH should be considered; otherwise, rebleeding may occur.
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