There are few studies analyzing stroke in women, taking into account the vascular risk factors, cause of stroke, clinical picture, and outcome. The purpose of this study was to analyze possible sex ...differences in patients suffering first-ever acute stroke.
From December 1995 to January 2002, 1581 patients with first-ever acute stroke were analyzed, taking into account sex, age, risk factors, clinical presentation, stroke subtype, treatment, and outcome data.
Mean age was higher in women than in men (P<0.001). Hypertension (P=0.0027) and cardioembolic disease (P=0.0035) were independent factors related to women. Alcohol overuse (P<0.001), smoking (P<0.001), and vascular peripheral disease (P=0.031) were related to the male sex. Women more often suffered aphasic disorders (P<0.001), visual field disturbances (P<0.05), and dysphagia (P<0.01) than men. There were no differences in hemorrhagic and ischemic strokes according to sex. Women suffered more cardioembolic strokes (P<0.001); men suffered more atherothrombotic (P<0.001) and lacunar strokes (P<0.05). Women who survived remained more disabled than men (P<0.001).
Sex determines some clear differences in patients suffering a first-ever stroke. Women were, on average, 6 years older than men and had a different profile of vascular risk factors and a different distribution of stroke subtypes. Women had a longer hospital stay and remained more disabled than men. The amelioration of hypertension control and increase in anticoagulant treatment in patients with atrial fibrillation would be the best options for preventing stroke, especially in women.
Few data are available on very early stroke recurrence evaluated within the first hours after onset of symptoms and outcome for unselected patients with first-ever mild stroke or TIA and symptomatic ...carotid stenosis > or =50%.
One hundred sixty-three patients with symptomatic carotid stenosis and initial mild stroke (121) or TIA (42) were evaluated within 6 hours from onset of symptoms in a single tertiary hospital. Neurological recurrence (NR) was defined as a clearly defined new neurological event (TIA or stroke) or an increase of 4 points in the initial NIHSS. The NR rate was determined at 72 hours, 7 days, and 14 days. Disability was defined as a score of 3 to 6 on the modified Rankin scale at 14 days.
Forty-five patients (27.6%) had NR, including 6 patients with 2 episodes in different time periods: 34 (20.9%) within the first 72 hours; 11 (6.7%) between 72 hours and 7 days; and 6 (3.7%) at 14 days. Only carotid stenosis > or =70% was associated with NR; diabetes was marginally associated. At 2 weeks, 19 patients (11.7%) had disability; 14 of them experienced NR in the first 72 hours.
Patients with first-ever mild stroke or TIA and symptomatic carotid stenosis are at high risk for NR, especially within the first 72 hours. Our results suggest the necessity of testing pharmacological or interventional strategies for use during the hyperacute stroke phase in these patients.
Intracerebral hemorrhage (ICH) is a complex and heterogeneous disease, and there is no effective treatment. Spontaneous ICH represents the final manifestation of different types of cerebral small ...vessel disease, usually categorized as: lobar (mostly related to cerebral amyloid angiopathy) and nonlobar (hypertension-related vasculopathy) ICH. Accurate phenotyping aims to reflect these biological differences in the underlying mechanisms and has been demonstrated to be crucial to the success of genetic studies in this field. This review summarizes how current knowledge on genetics and epigenetics of this devastating stroke subtype are contributing to improve the understanding of ICH pathophysiology and their potential role in developing therapeutic strategies.
OBJECTIVE:Little information is available about sex-related differences in intracerebral hemorrhage (ICH). This is a prospective observational study to describe the sex differences in demographics, ...vascular risk factors, stroke care, and outcomes in primary ICH.
METHODS:BasicMar is a hospital-based registry of all stroke patients admitted to a single public hospital that covers a population of 330,000. From 2005 to 2015, there were 515 consecutive acute primary ICH patients. Outcome data were obtained at 3 months.
RESULTS:More men than women had ICH (52.4% vs 47.6%); the women were older and had worse previous functional status than men, who were more likely to drink alcohol and smoke and to have ischemic heart disease and peripheral arterial disease. There were no sex differences in etiology, severity, or hemorrhage volume. ICH score was greater in women than in men (p = 0.018). Women had more lobar ICH than men (odds ratio adjusted by age was 1.75 95% confidence interval 1.18–2.58, p = 0.005). The quality of stroke care was similar in both sexes. Mortality at 3 months was 44.1% in women and 41.1% in men (p = 0.656), and 3-month poor outcome among survivors (modified Rankin Scale mRS score 3–5) 58.4% in women and 45.3% in men (p = 0.027). After adjustment for previous mRS and ICH score, there were no differences in 3-month mortality or poor outcome at 3 months between sexes.
CONCLUSIONS:Patients with ICH showed sex-related differences in demographic characteristics, ICH location, and vascular risk factors, but not in stroke care, 3-month mortality, or adjusted poor outcome.
Age and stroke severity are the main mortality predictors after ischemic stroke. However, chronological age and biological age are not exactly concordant. Age-related changes in DNA methylation in ...multiple CpG sites across the genome can be used to estimate biological age, which is influenced by lifestyle, environmental factors, and genetic variation. We analyzed the impact of biological age on 3-month mortality in ischemic stroke. We assessed 594 patients with acute ischemic stroke in a cohort from Hospital del Mar (Barcelona) and validated the results in an independent cohort. Demographic and clinical data, including chronological age, vascular risk factors, initial stroke severity (NIHSS score), recanalization treatment, and previous modified Rankin scale were registered. Biological age was estimated with an algorithm based on DNA methylation in 71 CpGs. Biological age was predictive of 3-month mortality (p = 0.041; OR = 1.05, 95% CI 1.00-1.10), independently of NIHSS score, chronological age, TOAST, vascular risk factors, and blood cell composition. Stratified by TOAST classification, biological age was associated with mortality only in large-artery atherosclerosis etiology (p = 0.004; OR = 1.14, 95% CI 1.04-1.25). As estimated by DNA methylation, biological age is an independent predictor of 3-month mortality in ischemic stroke regardless of chronological age, NIHSS, previous modified Rankin scale, and vascular risk factors.
OBJECTIVE:To analyze the effect of age-related DNA methylation changes in multiple cytosine-phosphate-guanine (CpG) sites (biological age b-age) on patient outcomes at 3 months after an ischemic ...stroke.
METHODS:We included 511 patients with first-ever acute ischemic stroke assessed at Hospital del Mar (Barcelona, Spain) as the discovery cohort. Demographic and clinical data, including chronological age (c-age), vascular risk factors, initial stroke severity, recanalization treatment, and previous and 3-month modified Rankin Scale (p-mRS and 3-mRS, respectively) were registered. B-age was estimated with an algorithm, based on DNA methylation in 71 CpGs. Bivariate analysis determined variables associated with 3-mRS for inclusion in ordinal multivariate analysis.
RESULTS:After ordinal regressions for 3-month ischemic stroke outcome (3-mRS), b-age was associated with outcome (odds ratio 1.04 95% confidence interval 1.01–1.07), nullifying c-age. Stepwise regression kept b-age, basal NIH Stroke Scale, sex, p-mRS, and recanalization treatment as better explanatory variables, instead of c-age. These results were successfully replicated in an independent cohort.
CONCLUSIONS:B-age, estimated by DNA methylation, is an independent predictor of ischemic stroke outcome regardless of chronological years.
The aim of our study was to identify factors associated with stroke recurrence after an initial minor stroke or transient ischemic attack (TIA) in a prospective hospital-series.
Included in the ...series were 689 patients with NIHSS lower than 4 at hospital admission. The end point was a new neurological event (worsening >/=4 points in the initial NIHSS was considered as recurrence) at 90 days (and additionally at 7 days). Factors based on two previous reported scores (ABCD and SPI-II) were analyzed in relation with stroke recurrence: age, duration of symptoms >1 hour, weakness, speech impairment, initial hypertension, hypertension, diabetes, coronary disease, minor stroke versus TIA, prior stroke, and heart failure. We also analyzed: gender, hyperlipidemia, severe alcohol intake (>60gr/d), current smoking habits, peripheral arterial disease, atrial fibrillation, acute lesion in initial head computed tomography, severe symptomatic extra or intracranial arterial disease (SSAD; arterial stenosis >/=70%), previous TIA, and vertebrobasilar event. Patients were also analyzed separately according to diagnosis of TIA or minor stroke.
90-day recurrence occurred in 111 patients (16.1%), whereas 62 patients had 7-day recurrence (9%). The independent variables associated with 90-day recurrence were: SSAD (OR=4.97), weakness (OR=3.25), speech impairment (OR=1.96), severe alcohol intake (OR=4.18), heart failure (OR=2.41), previous TIA (OR=4.62), and vertebrobasilar events (OR=2.87). SSAD was independently associated with 7-day recurrence (OR=7.73) and also for TIA (OR=3.45) and minor stroke (OR=5.15) patients.
An arterial study to discard SSAD would be necessary, in combination with clinical factors, to improve the identification of patients with a higher risk of 90-day recurrence after an initial minor stroke or TIA.
Hyperglycemia is a marker of poor outcome in acute ischemic stroke (IS) patients. We aimed at evaluating the effect of combined HbA1c and first glucose measurement values on 3-month mortality ...prediction.
In a prospective analysis, 1,317 first-ever IS patients with HbA1c values were classified by first glycemia value (<155, 155-199, ≥200 mg/dl). Three-month mortality was analyzed by glycemia category in nondiabetics, diabetics with good previous glucose control (PGC) (HbA1c <7%), and diabetics with poor PGC (HbA1c ≥7.0%).
Mortality at 3 months was 13.1%, with no differences (p = 0.339) between non-diabetes mellitus (DM) (12.3%), good PGC-DM (12.4%), and poor PGC-DM (15.6%) patients. The unadjusted relative risk of 3-month mortality for patients with glucose ≥200 mg/dl was 3.76 (95% CI 1.48-9.56) in non-DM, 6.10 (95% CI 1.76-21.09) in good PGC-DM, and 1.44 (95% CI 0.77-2.69) in poor PGC-DM. Glycemia cutoffs most highly correlated with mortality increased as PGC declined: 107 mg/dl in non-DM, 152 mg/dl in good PGC-DM, and 229 mg/dl in poor PGC-DM patients. Glycemia correlated with stroke severity in nondiabetics and diabetic patients with good PGC, but not in those with poor PGC.
HbA1c determination combined with first measured glucose value is useful to stratify mortality risk in IS patients: hyperglycemia is a poor prognostic marker in non-DM and DM patients with good PGC; results are inconsistent in poor PGC-DM patients. Our data suggest the relationship between hyperglycemia and poor outcome reflects stress response rather than a deleterious effect of glucose.
BACKGROUND AND PURPOSE—Although prolonged cardiac rhythm monitoring (PCM) can reveal a substantial proportion of ischemic stroke (IS) patients with atrial fibrillation not detected by conventional ...short-term monitoring, current guidelines indicate an uncertain clinical benefit for PCM. We evaluated the impact of PCM on secondary stroke prevention using data from available to date randomized clinical trials and observational studies.
METHODS—We performed a comprehensive literature search in MEDLINE, SCOPUS, CENTRAL (Cochrane Central Register of Controlled Trial), and conference proceedings to identify studies reporting stroke recurrence rates in patients with history of cryptogenic IS or transient ischemic attack (TIA) receiving PCM compared with patients receiving conventional (non-PCM) cardiac monitoring.
RESULTS—We included 4 studies (2 randomized clinical trials and 2 observational studies), including a total of 1102 patients (mean age68 years, 41% women). We documented an increased incidence of atrial fibrillation detection (risk ratio=2.46; 95% CI, 1.61–3.76) and anticoagulant initiation (risk ratio=2.07; 95% CI, 1.36–3.17) and decreased risk of recurrent stroke (risk ratio=0.45; 95% CI, 0.21–0.97) and recurrent stroke/TIA (risk ratio=0.49; 95% CI, 0.30–0.81) during follow-up for IS/TIA patients who underwent PCM compared with IS/TIA patients receiving conventional cardiac monitoring. In the subgroup analysis, according to study type, atrial fibrillation detection, anticoagulant initiation, and IS/TIA recurrence rates were comparable between PCM and non-PCM in randomized clinical trials and observational studies. No evidence of heterogeneity (I<12%) was documented across all the aforementioned subgroups.
CONCLUSIONS—We provide preliminary evidence for a potential impact of PCM on secondary stroke prevention, as patients with cryptogenic IS/TIA undergoing PCM had higher rates of atrial fibrillation detection, anticoagulant initiation, and lower stroke recurrence.
OBJECTIVETo describe short-term and 5-year rates of mortality and poor outcome in patients with spontaneous aneurysmal subarachnoid hemorrhage (aSAH) who received repair treatment.
METHODSIn this ...prospective observational study, mortality and poor outcome (modified Rankin Scale score 3–6) were analyzed in 311 patients with aSAH at 3 months, 1 year, and 5 years follow-up. Sensitivity analysis was performed according to treatment modality. In-hospital and 5-year complications were analyzed.
RESULTSOf 476 consecutive patients with spontaneous subarachnoid hemorrhage, 347 patients (72.9%) had aSAH. Of these, 311 (89.6%) were treated (242 endovascular, 69 neurosurgical), with a mean follow-up of 43.4 months (range, 1 to 145). Three-month, 1-year, and 5-year mortality was 18.4%, 22.9%, and 29.0%, and poor outcome was observed in 42.3%, 36.0%, and 36.0%, respectively. Adjusted poor outcome was lower in endovascular than in neurosurgical treatment at 3 months (odds ratio OR 0.36 95% confidence interval CI 0.18-0.74), with an absolute difference of 15.8% (number needed to treat = 6.3), and at 1 year (OR = 0.40 95% CI 0.20-0.81), with an absolute difference of 15.9% (number needed to treat = 6.3). Complications did not differ between the 2 procedures. However, mechanical ventilation was less frequent with the endovascular technique (OR 0.67 95% CI 0.54–0.84).
CONCLUSIONSPatients with aSAH treated according to current guidelines had a short-term mortality of 18.4% and 5-year mortality of 29%. The majority (64.0%) of patients remained alive without disabilities at 5-year follow-up. Patients prioritized to endovascular treatment had better outcomes than those referred to neurosurgery because endovascular coiling was not feasible.
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