Background and purpose
Little is currently known about the cost‐effectiveness of intensive care of acute ischemic stroke (AIS). We evaluated 1‐year costs and outcome for patients with AIS treated in ...the intensive care unit (ICU).
Materials and methods
A single‐center retrospective study of patients admitted to an academic ICU with AIS between 2003 and 2013. True healthcare expenditure was obtained up to 1 year after admission and adjusted to consumer price index of 2019. Patient outcome was 12‐month functional outcome and mortality. We used multivariate logistic regression analysis to identify independent predictors of favorable outcomes and linear regression analysis to assess factors associated with costs. We calculated the effective cost per survivor (ECPS) and effective cost per favorable outcome (ECPFO).
Results
The study population comprised 154 patients. Reasons for ICU admission were: decreased consciousness level (47%) and need for respiratory support (40%). There were 68 (44%) 1 year survivors, of which 27 (18%) had a favorable outcome. High age (odds ratio OR 0.95, 95% confidence interval CI 0.91–0.98) and high hospital admission National Institutes of Health Stroke Scale score (OR 0.92, 95% CI 0.87–0.97) were independent predictors of poor outcomes. Increased age had a cost ratio of 0.98 (95% CI 0.97–0.99) per added year. The ECPS and ECPFO were 115,628€ and 291,210€, respectively.
Conclusions
Treatment of AIS in the ICU is resource‐intense, and in an era predating mechanical thrombectomy the outcome is often poor, suggesting a need for further research into cost‐efficacy of ICU care for AIS patients.
In ischemic stroke patients, the incidence of prior cancer can be up to 16%,1 both diseases causing significant disability and loss of productive life-years. In a recent US-based nationwide registry ...study, about 10% of all hospitalized ischemic stroke patients had comorbid cancer, with a slight rise in this rate over the last decade.2 Stroke patients diagnosed with occult cancer are usually older with men being at a higher risk of having comorbid cancer.3,4 In addition, probability of cancer diagnosis after stroke is associated with smoking, elevated D-dimer, elevated C-reactive protein (CRP), and anemia on admission.
Objective
To assess the association between migraine and cryptogenic ischemic stroke (CIS) in young adults, with subgroup analyses stratified by sex and presence of patent foramen ovale (PFO).
...Methods
We prospectively enrolled 347 consecutive patients aged 18 to 49 years with a recent CIS and 347 age‐ and sex‐matched (±5 years) stroke‐free controls. Any migraine and migraine with (MA) and migraine without aura (MO) were identified by a screener, which we validated against a headache neurologist. We used conditional logistic regression adjusting for age, education, hypertension, diabetes, waist‐to‐hip ratio, physical inactivity, current smoking, heavy drinking, and oral estrogen use to assess independent association between migraine and CIS. The effect of PFO on the association between migraine and CIS was analyzed with logistic regression in a subgroup investigated with transcranial Doppler bubble screen.
Results
The screener performance was excellent (Cohen kappa > 0.75) in patients and controls. Compared with nonmigraineurs, any migraine (odds ratio OR = 2.48, 95% confidence interval CI = 1.63–3.76) and MA (OR = 3.50, 95% CI = 2.19–5.61) were associated with CIS, whereas MO was not. The association emerged in both women (OR = 2.97 for any migraine, 95% CI = 1.61–5.47; OR = 4.32 for MA, 95% CI = 2.16–8.65) and men (OR = 2.47 for any migraine, 95% CI = 1.32–4.61; OR = 3.61 for MA, 95% CI = 1.75–7.45). Specifically for MA, the association with CIS remained significant irrespective of PFO. MA prevalence increased with increasing magnitude of the right‐to‐left shunt in patients with PFO.
Interpretation
MA has a strong association with CIS in young patients, independent of vascular risk factors and presence of PFO. ANN NEUROL 2021;89:242–253
Objectives
Current guidelines for recanalization treatment are based on the time elapsed between symptom onset and treatment and visualization of existing penumbra in computed tomography perfusion ...(CTP) imaging. The time window for treatment options relies on linear growth of infarction although individual infarct growth rate may vary.
We aimed to test how accurately the estimated follow‐up infarct volume (eFIV) can be approximated by using a linear growth model based on CTP baseline imaging. If eFIV did not fall within the margins of +/− 19% of the follow‐up infarct volume (FIV) measured at 24 h from non‐enhanced computed tomography images, the results would imply that the infarct growth is not linear.
Materials and Methods
All consecutive endovascularly treated (EVT) patients from 11/2015 to 9/2019 at the Helsinki University Hospital with large vessel occlusion (LVO), CTP imaging, and known time of symptom onset were included. Infarct growth rate was assumed to be linear and calculated by dividing the ischemic core volume (CTPcore) by the time from symptom onset to baseline imaging. eFIV was calculated by multiplying the infarct growth rate with the time from baseline imaging to recanalization or in case of futile recanalization to follow‐up imaging at 24 h, limited to the penumbra. Collateral flow was estimated by calculating hypoperfusion intensity ratio (HIR).
Results
Of 5234 patients, 48 had LVO, EVT, CTP imaging, and known time of symptom onset. In 40/48 patients (87%), infarct growth was not linear. HIR did not differ between patients with linear and nonlinear growth (p > .05). As expected, in over half of the patients with successful recanalization eFIV exceeded FIV.
Conclusions
Infarct growth was not linear in most patients and thus time elapsed from symptom onset and CTPcore appear to be insufficient parameters for clinical decision‐making in EVT candidates.
Objective
Seizure at onset (SaO) has been considered a relative contraindication for intravenous thrombolysis (IVT) in patients with acute ischemic stroke, although this appraisal is not evidence ...based. Here, we investigated the prognostic significance of SaO in patients treated with IVT for suspected ischemic stroke.
Methods
In this multicenter, IVT‐registry–based study we assessed the association between SaO and symptomatic intracranial hemorrhage (sICH, European Cooperative Acute Stroke Study II definition), 3‐month mortality, and 3‐month functional outcome on the modified Rankin Scale (mRS) using unadjusted and adjusted logistic regression, coarsened exact matching, and inverse probability weighted analyses.
Results
Among 10,074 IVT‐treated patients, 146 (1.5%) had SaO. SaO patients had significantly higher National Institutes of Health Stroke Scale score and glucose on admission, and more often female sex, prior stroke, and prior functional dependence than non‐SaO patients. In unadjusted analysis, they had generally less favorable outcomes. After controlling for confounders in adjusted, matched, and weighted analyses, all associations between SaO and any of the outcomes disappeared, including sICH (odds ratio ORunadjusted = 1.53 95% confidence interval (CI) = 0.74–3.14, ORadjusted = 0.52 95% CI = 0.13–2.16, ORmatched = 0.68 95% CI = 0.15–3.03, ORweighted = 0.95 95% CI = 0.39–2.32), mortality (ORunadjusted = 1.49 95% CI = 1.00–2.24, ORadjusted = 0.98 95% CI = 0.5–1.92, ORmatched = 1.13 95% CI = 0.55–2.33, ORweighted = 1.17 95% CI = 0.73–1.88), and functional outcome (mRS ≥ 3/ordinal mRS: ORunadjusted = 1.33 95% CI = 0.96–1.84/1.35 95% CI = 1.01–1.81, ORadjusted = 0.78 95% CI = 0.45–1.32/0.78 95% CI = 0.52–1.16, ORmatched = 0.75 95% CI = 0.43–1.32/0.45 95% CI = 0.10–2.06, ORweighted = 0.87 95% CI = 0.57–1.34/1.00 95% CI = 0.66–1.52). These results were consistent regardless of whether patients had an eventual diagnosis of ischemic stroke (89/146) or stroke mimic (57/146 SaO patients).
Interpretation
SaO was not an independent predictor of poor prognosis. Withholding IVT from patients with assumed ischemic stroke presenting with SaO seems unjustified. ANN NEUROL 2019;86:770–779
Background Recent studies have shown an increasing prevalence of vascular risk factors in young adults with ischemic stroke ( IS ). However, the strength of the association between all vascular risk ...factors and early-onset IS has not been fully established. Methods and Results We compared 961 patients with a first-ever IS at 25 to 49 years to 1403 frequency-matched stroke-free controls from a population-based cohort study ( FINRISK ). Assessed risk factors included an active malignancy, atrial fibrillation, cardiovascular disease, current smoking status, a family history of stroke, high low-density lipoprotein cholesterol, high triglycerides, low high-density lipoprotein cholesterol, hypertension, and type 1 and type 2 diabetes mellitus. We performed subgroup analyses based on age, sex, and IS etiology. In a fully adjusted multivariable logistic regression analysis, significant risk factors for IS consisted of atrial fibrillation (odds ratio OR, 10.43; 95% confidence interval CI , 2.33-46.77, cardiovascular disease (OR, 8.01; 95% CI , 3.09-20.78), type 1 diabetes mellitus (OR, 6.72; 95% CI , 3.15-14.33), type 2 diabetes mellitus (OR, 2.31; 95% CI , 1.35-3.95), low high-density lipoprotein cholesterol (OR, 1.81; 95% CI , 1.37-2.40), current smoking status (OR, 1.81; 95% CI , 1.50-2.17), hypertension (OR, 1.43; 95% CI , 1.17-1.75), and a family history of stroke (OR, 1.37; 95% CI , 1.04-1.82). High low-density lipoprotein cholesterol exhibited an inverse association with IS . In the subgroup analyses, the most consistent associations appeared for current smoking status and type 1 diabetes mellitus. Conclusions Our study establishes the associations between 11 vascular risk factors and early-onset IS , among which atrial fibrillation, cardiovascular disease, and both type 1 and 2 diabetes mellitus in particular showed strong associations.
Background Ischemic stroke in young individuals often remains cryptogenic. Some of these strokes likely originate from the heart, and atrial fibrosis might be one of the etiological mechanisms. In ...this pilot study, we investigated whether advanced echocardiography findings of the left atrium (LA) of young cryptogenic stroke patients differ from those of stroke-free controls. Methods and Results We recruited 30 cryptogenic ischemic stroke patients aged 18 to 49 years and 30 age- and sex-matched stroke-free controls among participants of the SECRETO (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome) study (NCT01934725). We measured basic left ventricular parameters and detailed measures of the LA, including 4-dimensional volumetry, speckle tracking epsilon, strain rate, and LA appendix orifice variation. Data were compared as continuous parameters and by tertiles. Compared with controls, stroke patients had smaller LA reservoir volumes (10.2 interquartile range, 5.4 versus 13.2 5.4 mL;
=0.030) and smaller positive epsilon values (17.8 8.5 versus 20.8 10.1;
=0.023). In the tertile analysis, stroke patients had significantly lower left atrial appendage orifice variation (3.88 0.75 versus 4.35 0.90 mm;
=0.043), lower LA cyclic volume change (9.2 2.8 versus 12.8 3.5 mL;
=0.023), and lower LA contraction peak strain rate (-1.8 0.6 versus -2.3 0.6;
=0.021). We found no statistically significant differences in left ventricular measures. Conclusions This preliminary comparison suggests altered LA dynamics in young patients with cryptogenic ischemic stroke, and thus that LA wall pathology might contribute to these strokes. Our results await confirmation in a larger sample.
Background
Ischaemic stroke in young individuals often remains cryptogenic. In this pilot study, we investigated, whether advanced echocardiography methods could find differences in the diastolic ...function between young cryptogenic stroke patients and stroke‐free controls.
Methods
We recruited 30 cryptogenic ischaemic stroke patients aged 18–49 and 30 age‐ and sex‐matched stroke‐free controls among participants of the Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO) study (NCT01934725). We measured diastolic function parameters derived from speckle tracking strain rate, Doppler techniques and 4D volumetry. We also performed statistical analyses comparing only the highest and lowest tertile of cases and controls for each parameter.
Results
None of our patients or controls had diastolic dysfunction according to ASE/EACVI criteria. However, compared to stroke‐free controls, the stroke patient group had lower E/A ratio of mitral inflow, lower lateral and mean e’, lower A/a’ ratio, lower strain rate in early diastole and lower speckle tracking‐derived e/a ratio. When comparing the lowest tertiles, patients also had a lower peak filling rate by 4D volumetry, a lower peak early filling fraction (fraction of left ventricular filling during early diastole), and lower velocities in a series of the tissue Doppler‐derived diastolic parameters and blood flow/tissue velocity ratios.
Conclusion
Our study displayed subtle differences in diastolic function between patients and stroke‐free controls, which may play a role in early‐onset cryptogenic stroke. The differences were clearer when the lowest tertiles were compared, suggesting that there is a subgroup of young cryptogenic stroke patients with subclinical heart disease.
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