What Is a Minor Stroke? FISCHER, Urs; BAUMGARTNER, Adrian; MATTLE, Heinrich P ...
Stroke (1970),
04/2010, Letnik:
41, Številka:
4
Journal Article
Recenzirano
Odprti dostop
The term "minor stroke" is often used; however a consensus definition is lacking. We explored the relationship of 6 "minor stroke" definitions and outcome and tested their validity in subgroups of ...patients.
A total of 760 consecutive patients with acute ischemic strokes were classified according to the following definitions: A, score < or = 1 on every National Institutes of Health Stroke Scale (NIHSS) item and normal consciousness; B, lacunar-like syndrome; C, motor deficits with or without sensory deficits; D, NIHSS < or = 9 excluding those with aphasia, neglect, or decreased consciousness; E, NIHSS < or = 9; and F, NIHSS < or = 3. Short-term outcome was considered favorable when patients were discharged home, and favorable medium-term outcome was defined as a modified Rankin Scale score of < or = 2 at 3 months. The following subgroup analyses were performed by definition: sex, age, anterior versus posterior and right versus left hemispheric stroke, and early (0 to 6 hours) versus late admission (6 to 24 hours) to the hospital.
Short-term and medium-term outcomes were most favorable in patients with definition A (74% and 90%, respectively) and F (71% and 90%, respectively). Patients with definition C and anterior circulation strokes were more likely to be discharged home than patients with posterior circulation strokes (P=0.021). The medium-term outcome of older patients with definition E was less favorable compared with the outcome of younger ones (P=0.001), whereas patients with definition A, D, and F did not show different outcomes in any subgroup.
Patients fulfilling definition A and F had best short-term and medium-term outcomes. They would be best suited to the definition of "minor stroke."
Transient elevation of arterial blood pressure (BP) is frequent in acute ischemic stroke and may help to increase perfusion of tissue jeopardized by ischemia. If this is true, recanalization may ...eliminate the need for this BP elevation.
We analyzed BP in 149 patients with acute ischemic stroke on admission to the hospital and 1 and 12 hours after intraarterial thrombolysis. BP values of patients with adequate recanalization were compared with BP values of patients with inadequate recanalization. Recanalization was determined on cerebral arteriography after thrombolysis using thrombolysis in myocardial infarction grades.
Systolic, mean, and diastolic arterial BP decreased significantly from admission to 12 hours after thrombolysis in all patients (P<0.001). Before thrombolysis, patients with adequate and inadequate recanalization showed equal systolic (147.4 and 148.0 mm Hg), mean (102.1 and 104.1 mm Hg), and diastolic (79.5 and 82.1 mm Hg) BP values. Twelve hours after thrombolysis, patients with adequate recanalization had lower values than those with inadequate recanalization (systolic BP, 130 versus 139.9 mm Hg; mean BP, 86.8 versus 92.2 mm Hg; and diastolic, BP 65.2 versus 68.3 mm Hg). Two-way repeated ANOVA analysis showed a significant group x time interaction for systolic BP, indicating a larger systolic BP decrease when recanalization succeeded (P=0.019).
The course of elevated systolic but not diastolic BP after acute ischemic stroke was found to be inversely associated with the degree of vessel recanalization. When recanalization failed, systolic BP remained elevated longer than when it succeeded.
We report of a 75-year-old patient with stroke-like presentation, where cerebral imaging led to the diagnosis of a massive arteriovenous malformation (AVM) of the whole left hemisphere. We suggest ...considering AVM as a differential diagnosis in patients with symptoms of acute stroke despite age and, in the absence of contraindications, in this setting to obtain MRI or CT angiography of the brain.
Zusammenfassung. Berichtet wird über einen Fall aus der onkologischen und neurologischen Praxis. Ein Patient entwickelte unter der neoadjuvanten Radiochemotherapie mit Capecitabin bei Rektumkarzinom ...eine sensible Polyneuropathie sowie eine leichte motorische Schwäche der linken Extremiäten, einhergehend mit ipsilateraler Hyperreflexie und paresebedingter Gangstörung. Als ursächlich für die Polyneuropathie wird eine Toxizität durch Capecitabin angenommen. Die Hemiparese resultierte retrospektiv betrachtet jedoch eher aus einer akuten Varizella-Zoster-Virus-Myelitis, einer seltenen Komplikation eines Herpes-Zoster-Infekts, die aufgrund der Immunsuppression durch die Chemotherapie und auch durch die Tumorerkrankung selbst begünstigt wurde.
Really Just a Side Effect of Capecitabine? Case Report from the Oncological and Neurological Consultation
A case of our oncology and neurology department is presented. A male patient developed ...sensory polyneuropathy and mild left-side hemiparesis while receiving neoadjuvant radiochemotherapy with capecitabine as treatment for rectal cancer. Polyneuropathy as a side effect of capecitabine was thought to be the culprit. But upper motor neuron signs were highly supposed to be caused by an acute varicella zoster myelitis, a rare complication of varicella zoster infection possibly facilitated by immunosuppression due to chemotherapy.
Background
Stroke patients with diabetes and admission hyperglycaemia have worse outcomes than non-diabetics, with or without intravenous thrombolysis. Poor vessel recanalization was reported in ...diabetics treated with intravenous thrombolysis.
Aims
This study aimed to determine the impact of admission glucose and diabetes on recanalization and outcome after intra-arterial thrombolysis.
Methods
We analysed 389 patients (213 men, 176 women) treated with intra-arterial thrombolysis. The association of diabetes and admission glucose value with recanalization, outcome, mortality, and symptomatic intracranial haemorrhage was determined. Recanalization was classified according to thrombolysis in myocardial infarction grades. Outcome was measured using the modified Rankin Scale at three-months and categorized as favourable (modified Rankin Scale 0–2) or poor (modified Rankin Scale 3–6).
Results
The rate of partial or complete recanalization (thrombolysis in myocardial infarction 2–3) did not differ between patients with and without diabetes (67% vs. 66%; P = 1·000). Mean admission glucose values were similar in patients with poor recanalization (thrombolysis in myocardial infarction 0–1) and patients with partial or complete recanalization (thrombolysis in myocardial infarction 2–3; 7·3 vs. 7·3 mmol/l; P = 0·746). Follow-up at three-months was obtained in 388 of 389 patients. Clinical outcome was favourable (modified Rankin Scale 0–2) in 189 patients (49%) and poor (modified Rankin Scale 3–6) in 199 patients (51%). Mortality at three-months was 20%. Diabetics were more likely to have poor outcome (72% vs. 48%; P = 0·001) and to be dead (30% vs. 19%; P = 0·044) at three-months. After multivariable analysis, there remained an independent relationship between diabetes and outcome (P = 0·003; odds ratio 3·033, 95% confidence interval 1·452–6·336), but not with mortality (P = 0·310; odds ratio 1·436; 95% confidence interval 0·714–2·888). Moreover, higher age (P = 0·001; odds ratio 1·039; 95% confidence interval 1·017–1·061), higher baseline National Institutes of Health Stroke Scale score (P < 0·0001; odds ratio 1·130; 95% confidence interval 1·079–1·182), location of vessel occlusion as categorical variable (P < 0·0001), poor collaterals (P = 0·02; odds ratio 1·587; 95% confidence interval 1·076–2·341), poor vessel recanalization (P < 0·0001; odds ratio 4·713; 95% confidence interval 2·627–8·454), and higher leucocyte count (P = 0·032; odds ratio 1·094; 95% confidence interval 1·008–1·188) were independent baseline predictors of poor outcome. Higher admission glucose was associated with poor outcome (P = 0·006) and mortality (P < 0·0001). After multivariate analyses, glucose remained independently associated with poor outcome (P = 0·019; odds ratio 1·150; 95% confidence interval 1·023-1-292) and mortality (P = 0·005; odds ratio 1·183; 95% confidence interval 1052–1·331). The rate of symptomatic intracranial haemorrhage was similar in diabetics and non-diabetics (6·7% vs. 4·6%; P = 0·512). Mean admission glucose was higher in patients with symptomatic intracranial haemorrhage than without (8·58 vs. 7·26 mmol/l; P = 0·010). Multivariable analysis confirmed an independent association between admission glucose and symptomatic intracranial haemorrhage (P = 0·027; odds ratio 1·187; 95% confidence interval 1·020–1·381).
Conclusions
Diabetes and glucose value on admission did not influence recanalization after intra-arterial thrombolysis; nevertheless, they were independent predictors of poor outcome after intra-arterial thrombolysis and a higher admission glucose value was an independent predictor of symptomatic intracranial haemorrhage. This indicates that factors on the capillary, cellular, or metabolic level may account for the worse outcome in patients with elevated glucose value and diabetes.
Background
Comparisons between younger and older stroke patients including comorbidities are limited.
Methods
Prospective data of consecutive patients with first ever acute ischemic stroke were ...compared between younger (≤ 45 years) and older patients (> 45 years).
Results
Among 1004 patients, 137 (14 %) were ≤ 45 years. Younger patients were more commonly female (57 % versus 34 %; p < 0.0001), had a lower frequency of diabetes (1 % versus 15 %; p < 0.0001), hypercholesterolemia (26 % versus 56 %; p < 0.0001), hypertension (19 % versus 65 %; p < 0.0001), coronary heart disease (14 % versus 40 %; p < 0.0001), and a lower mean Charlson co-morbidity index (CCI), (0.18 versus 0.84; p < 0.0001). Tobacco use was more prevalent in the young (39 % versus 26 %; P < 0.0001). Large artery disease (2 % versus 21 %; p < 0.0001), small artery disease (3 % versus 12 %; p = 0.0019) and atrial fibrillation (1 % versus 17 %; p = 0.001) were less common in young patients, while other etiologies (31 % versus 9 %; p < 0.0001), patent foramen ovale or atrial septal defect (44 % versus 26 %; p < 0.0001), and cervical artery dissection (26 % versus 7 %; p < 0.0001) were more frequent. A favorable outcome (mRS 0 or 1) was more common (57.4 % versus 46.9 %; p = 0.023), and mortality (5.1 % versus 12 %; p = 0.009) was lower in the young. After regression analysis, there was no independent association between age and outcome (p = 0.206) or mortality (p = 0.073). Baseline NIHSS score (p < 0.0001), diabetes (p = 0.041), and CCI (p = 0.002) independently predicted an unfavorable outcome.
Conclusions
Younger patients were more likely to be female, had different risk factors and etiologies and fewer co-morbidities. There was no independent association between age and clinical outcome or mortality.
Recent studies have reported sex differences in recanalization and outcome after intravenous thrombolysis (IVT) in acute ischemic stroke.
We analyzed sex differences in outcome in consecutive ...patients with middle cerebral artery (MCA) M1 or M2 and internal carotid artery (ICA) occlusion treated with intra-arterial thrombolysis (IAT). Recanalization immediately after thrombolysis and outcome after 3 months were assessed.
Two hundred five patients (111 men) with MCA and 43 (22 men) with ICA occlusion were identified. Baseline variables did not differ between the sexes except for a higher prevalence of smokers among men in the MCA group (31% vs 12%; P=0.001). Partial or complete recanalization (TIMI flow 2 or 3) of the MCA was observed in 71 (75%) women and 80 (72%) men (P=0.488). In the ICA group, 14 (67%) women and 11 men (50%) showed TIMI 2 or 3 recanalization (P=0.425). Favorable outcome (modified Rankin Scale score 0 to 2) was seen in 57 women (61%) and 63 men (57%) with MCA occlusion (P=0.512) and in 6 women (28%) and 4 men (18%) with ICA occlusion (P=0.656). After multiple-regression analyses, there was still no association between sex and outcome (P=0.763 for MCA and P=0.813 for ICA occlusion) or recanalization (P=0.488 for MCA and P=0.104 for ICA occlusion).
There was no association between sex and recanalization or outcome after IAT. These findings are in contrast to previous studies reporting better recanalization and outcome after IVT in women and might have implications in the selection of patients for IAT or IVT.
Time delays from stroke onset to arrival at the hospital are the main obstacles for widespread use of thrombolysis. In order to decrease the delays, educational campaigns try to inform the general ...public how to act optimally in case of stroke. To determine the content of such a campaign, we assessed the stroke knowledge in our population.
The stroke knowledge was studied by means of a closed-ended questionnaire. 422 randomly chosen inhabitants of Bern, Switzerland, were interviewed.
The knowledge of stroke warning signs (WS) was classified as good in 64.7%. A good knowledge of stroke risk factors (RF) was noted in 6.4%. 4.2% knew both the WS and the RF of stroke indicating a very good global knowledge of stroke. Only 8.3% recognized TIA as symptoms of stroke resolving within 24 hours, and only 2.8% identified TIA as a disease requiring immediate medical help. In multivariate analysis being a woman, advancing age, and having an afflicted relative were associated with a good knowledge of WS (p = 0.048, p < 0.001 and p = 0.043). Good knowledge of RF was related to university education (p < 0.001). The good knowledge of TIA did not depend on age, sex, level of education or having an afflicted relative.
The study brings to light relevant deficits of stroke knowledge in our population. A small number of participants could recognize TIA as stroke related symptoms resolving completely within 24 hours. Only a third of the surveyed persons would seek immediate medical help in case of TIA. The information obtained will be used in the development of future educational campaigns.
Intra-arterial thrombolysis (IAT) can improve clinical outcome in patients with acute basilar artery occlusion (BAO). The purpose of this study was to determine whether the severity of neurological ...symptoms, the extent of early ischemic damage on pretreatment diffusion-weighted MRI (DWI), and the lesion progression or regression on post-treatment MRI can predict functional outcome in patients with BAO treated with IAT.
Thirty-six BAO patients (13 women, 23 men; mean age 60 years) treated with IAT within 12 h of symptom onset were studied. Early ischemic damage on DWI was assessed by applying 4 DWI scoring systems, including a proposed DWI score developed for this study. The latter was used for evaluation of lesion dynamics on post-treatment MRI. The association of pretreatment DWI, severity of symptoms (National Institutes of Health Stroke Scale, NIHSS, and Glasgow Coma Scale, GCS, scores), vessel recanalization, and lesion progression or regression after IAT with clinical outcome at 3 months was analyzed.
Median NIHSS and GCS scores on admission were 17 and 10, respectively. In univariate analysis, NIHSS and GCS scores (on admission) and all 4 DWI scores were significantly associated with clinical outcome. After regression analysis for each DWI score, the DWI score proposed herein was the only score that remained independently associated with clinical outcome at 3 months (p = 0.004). A decrease in DWI score was observed in 3 of 23 patients with post-IAT MRI. Successful recanalization was significantly associated with lesion regression (p = 0.044).
BAO patients with less extensive tissue damage on DWI and milder neurological deficits (lower NIHSS and higher GCS) have a better clinical outcome following IAT. The introduced DWI score reliably quantified the pretreatment ischemic damage and was an independent predictor of functional outcome. Lesion regression on DWI score after IAT was associated with vessel recanalization (p = 0.44), but had no impact on clinical outcome.
PDF
