OBJECTIVE:To determine whether higher neutrophil counts before IV recombinant tissue plasminogen activator (rtPA) administration in ischemic stroke (IS) patients are associated with symptomatic ...intracerebral hemorrhages (sICH) and worse outcomes at 3 months.
METHODS:Blood samples for leukocyte, neutrophil, and lymphocyte counts were drawn before IV rtPA administration in IS patients included in the cohorts of Lille and Helsinki. The primary endpoint was sICH (European Cooperative Acute Stroke–II definition). Secondary endpoints were death and excellent (modified Rankin Scale mRS score 0–1 or equal to prestroke mRS) and good (mRS score 0–2 or equal to prestroke mRS) outcomes at 3 months.
RESULTS:We included 846 patients (median age 71 years; 50.8% men). The neutrophil count and neutrophil to lymphocyte ratio (NLR) were independently associated with the 4 endpointssICH (adjusted odds ratio adjOR for an increase of 1,000 neutrophils = 1.21 and adjOR 1.11, respectively), death (adjOR 1.16 and adjOR 1.08), and excellent (adjOR 0.87 and adjOR 0.85) and good (adjOR 0.86 and adjOR 0.91) outcomes. The total leukocyte count was not associated with any of the 4 endpoints. The best discriminating factor for sICH was NLR ≥4.80 (sensitivity 66.7%, specificity 71.3%, likelihood ratio 2.32). Patients with NLR ≥4.80 had a 3.71-fold increased risk for sICH (95% confidence interval adjOR1.97–6.98) compared to patients with NLR <4.80.
CONCLUSIONS:Higher neutrophil counts and NLR are independently associated with sICH and worse outcome at 3 months. The identification of mediators of this effect could provide new targets for neuroprotection in patients treated by rtPA.
Objective:
A study was undertaken to develop a score for assessing risk for symptomatic intracranial hemorrhage (sICH) in ischemic stroke patients treated with intravenous (IV) thrombolysis.
Methods:
...The derivation cohort comprised 974 ischemic stroke patients treated (1995–2008) with IV thrombolysis at the Helsinki University Central Hospital. The predictive value of parameters associated with sICH (European Cooperative Acute Stroke Study II) was evaluated, and we developed our score according to the magnitude of logistic regression coefficients. We calculated absolute risks and likelihood ratios of sICH per increasing score points. The score was validated in 828 patients from 3 Swiss cohorts (Lausanne, Basel, and Geneva). Performance of the score was tested with area under a receiver operating characteristic curve (AUC‐ROC).
Results:
Our SEDAN score (0 to 6 points) comprises baseline blood Sugar (glucose; 8.1–12.0mmol/l 145–216mg/dl = 1; >12.0mmol/l >216 mg/dl = 2), Early infarct signs (yes = 1) and (hyper)Dense cerebral artery sign (yes = 1) on admission computed tomography scan, Age (>75 years = 1), and NIH Stroke Scale on admission (≥10 = 1). Absolute risk for sICH in the derivation cohort was: 1.4%, 2.9%, 8.5%, 12.2%, 21.7%, and 33.3% for 0, 1, 2, 3, 4, and 5 score points, respectively. In the validation cohort, absolute risks were similar (1.0%, 3.5%, 5.1%, 9.2%, 16.9%, and 27.8%, respectively). AUC‐ROC was 0.77 (0.71–0.83; p < 0.001).
Interpretation:
Our SEDAN score reliably assessed risk for sICH in IV thrombolysis‐treated patients with anterior‐ and posterior circulation ischemic stroke, and it can support clinical decision making in high‐risk patients. External validation of the score supports its generalization. ANN NEUROL 2012;
BACKGROUND AND PURPOSE—Seizures are a common complication of intracerebral hemorrhage (ICH). We developed a novel tool to quantify this risk in individual patients.
METHODS—Retrospective analysis of ...the observational Helsinki ICH Study (n=993; median follow-up, 2.7 years) and the Lille Prognosis of InTra-Cerebral Hemorrhage (n=325; 2.2 years) cohorts of consecutive ICH patients admitted between 2004 and 2010. Helsinki ICH Study patients’ province-wide electronic records were evaluated for early seizures occurring within 7 days of ICH and among 7-day survivors (n=764) for late seizures (LSs) occurring >7 days from ICH. A Cox regression model estimating risk of LSs was used to derive a prognostic score, validated in the Prognosis of InTra-Cerebral Hemorrhage cohort.
RESULTS—Of the Helsinki ICH Study patients, 109 (11.0%) had early seizures within 7 days of ICH. Among the 7-day survivors, 70 (9.2%) patients developed LSs. The cumulative risk of LSs was 7.1%, 10.0%, 10.2%, 11.0%, and 11.8% at 1 to 5 years after ICH, respectively. We created the CAVE score (0–4 points) to estimate the risk of LSs, with 1 point for each of cortical involvement, age <65 years, volume >10 mL, and early seizures within 7 days of ICH. The risk of LSs was 0.6%, 3.6%, 9.8%, 34.8%, and 46.2% for CAVE scores 0 to 4, respectively. The c-statistic was 0.81 (0.76–0.86) and 0.69 (0.59–0.78) in the validation cohort.
CONCLUSIONS—One in 10 patients will develop seizures after ICH. The risk of this adverse outcome can be estimated by a simple score based on baseline variables.
Around 30-60% of patients with basilar artery occlusion (BAO) present with coma, which is often considered as a hallmark of poor prognosis.
To examine factors that will help predict outcomes in ...patients with BAO comatose on admission.
A total of 312 patients with angiography-proven BAO were analyzed. Comas were assessed as Glasgow Coma Scale (GCS) of ≤8 or impaired level of consciousness ascertained in the medical records. Outcomes were evaluated with the modified Rankin Scale (mRS) over a phone call at 3 months. In our study, 53 patients were excluded due to inadequate data on the level of consciousness.
In total, 103/259 (39.8%) of BAO patients were comatose on admission. Factors associated with acute coma were higher age, coronary artery disease, convulsions, extent of early ischemia by posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) < 8, absence of patent posterior collateral vasculature, and occlusion over multiple segments of BA. A total of 21/103 (20.4%) of comatose patients had a favorable outcome (mRS 0-3), and 12/103 (11.7%) had a good outcome (mRS 0-2). Factors associated with a favorable outcome in comatose BAO patients were younger age (
= 0.010), less extensive baseline ischemia (
= 0.027), recanalization (
= 0.013), and avoiding symptomatic intracranial hemorrhage (sICH) (
= 0.038). Factors associated with the poorest outcome or death (mRS 5-6) were older age (
= 0.001), diabetes (
= 0.022), atrial fibrillation (
= 0.016), lower median GCS 4 (IQR 3.6) vs. 6 (5-8);
= 0.006, pc-ASPECTS < 8 (
= 0.003), unsuccessful recanalization (
= 0.006), and sICH (
= 0.010). Futile recanalization (mRS 4-6) was significantly more common in comatose patients (49.4 vs. 18.5%,
< 0.001).
One in five BAO patients with acute coma had a favorable outcome. Older patients with cardiovascular comorbidities and already existing ischemic lesions before reperfusion therapies tended to have a poor prognosis, especially if no recanalization is achieved and sICH occurred.
Cerebral amyloid angiopathy (CAA) predisposes to symptomatic intracerebral hemorrhage (sICH) after combined thrombolytic and anticoagulant treatment of acute myocardial infarction. However, the role ...of CAA in stroke thrombolysis has not been established. Here, we describe a confirmed case of CAA‐related hemorrhage in a patient receiving thrombolysis for acute ischemic stroke. On autopsy, immunohistochemistry revealed amyloid‐β positive staining in thickened cortical and meningeal arteries at sites of hemorrhage. Further research is urgently needed to determine the hemorrhage risk related to CAA in stroke thrombolysis and develop better diagnostic tools to identify CAA in the emergency room.
•The EVT has been proved superior in acute stroke due to large vessel occlusion.•No RCTs exist comparing IVT + EVT and EVT alone.•Present nonrandomized studies suggest more favorable outcome with ...combined IVT + EVT.•Safety of combined IVT + EVT is also supported by the meta-analyses.•Contraindications for tPA leave the stage for EVT alone.
The superiority of endovascular treatment (EVT) in acute stroke due to large vessel occlusion has been proven in recent randomized trials. Yet, there are no randomized trials which have tested the additive effect of standard treatment with intravenous thrombolysis (IVT) as pretreatment to EVT over EVT treatment alone. So far, the EVT treatment groups of RCTs most often had pretreatment with IVT. The current guidelines on acute stroke treatment rely on meta-analyses and systematic analyses from RCTs and observational studies on pretreatment with IVT + EVT. Clinicians also apply their clinical experience and local “in-house” protocols.
We performed literature search on randomized controlled trials, systematic and meta-analyses and observational studies on recanalization therapies including intravenous thrombolysis and endovascular treatment or thrombectomy in acute stroke. Here we present a review and an opinion on the current choice of treatment modalities.
Hemifacial spasm (HFS) is a movement disorder of facial muscles innervated by the facial nerve. This condition often demands regular utilization of healthcare resources. However, knowledge of the ...incidence and prevalence of this condition is based on scarce studies. This research aimed to identify the incidence and prevalence of HFS in Finland's largest hospital district.
This retrospective study was conducted in the largest hospital district in Finland (Helsinki and Uusimaa). The study included consecutive HFS patients who visited the departments of Neurology and Neurosurgery in the Hospital District of Helsinki and Uusimaa between 2014 and 2019. The demographics included sex, side of the spasm, treatment allocations, duration of symptoms before diagnosis, and age at the time of diagnosis.
279 patients were identified from the medical records. 62% of patients were women and had left-sided spasms. The crude mean incidence among women was almost double that of men (1.86 vs. 0.94). The highest crude mean annual incidence among men was in the age group 60–79 years, while among women, it peaked in the age group 80 years and over. The mean annual age-standardized incidence of HFS was 1.53, 1.94 in women, and 1.05 in men. The mean age-standardized yearly prevalence was 10.62, 11.62 among women, and 9.31 among men. The annual age-standardized prevalence of HFS increased steadily from 2014 to 2019.
The incidence and prevalence of women outnumbered men. HFS is typically left-sided. The HFS incidence peaked after 80 years in women and men aged 60–79 years.
•Hemifacial spasm.•Incidence 1.53 (ASR).•prevalence 10.62 (ASR).•Broad age groups.
Treating hyperglycemia in acute ischemic stroke may be beneficial, but knowledge on its prognostic value and optimal target glucose levels is scarce. We investigated the dynamics of glucose levels ...and the association of hyperglycemia with outcomes on admission and within 48 h after thrombolysis.
We included 851 consecutive patients with acute ischemic stroke treated with intravenous thrombolysis in the Helsinki University Central Hospital during 1998-2008. Outcome measures were unfavorable 3- month outcome (3-6 on the modified Rankin Scale), death, and symptomatic intracerebral hemorrhage (sICH) according to NINDS criteria. Hyperglycemia was defined as a blood glucose level of ≥8.0 mmol/l. Four groups were identified based on (a) admission and (b) peak glucose levels 48 h after thrombolysis: (1) persistent normoglycemia (baseline plus 48-hour normoglycemia), (2) baseline hyperglycemia (48-hour normoglycemia), (3) 48-hour hyperglycemia (baseline normoglycemia), and (4) persistent hyperglycemia (baseline plus 48-hour hyperglycemia).
480 (56.4%) of our patients (median age 70 years; onset-to-needle time 199 min; National Institutes of Health Stroke Scale score 9), had persistent normoglycemia, 59 (6.9%) had baseline hyperglycemia, 175 (20.6%) had 48-hour hyperglycemia, while persistent hyperglycemia appeared in 137 (16.1%) patients. Persistent and 48-hour hyperglycemia independently predicted unfavorable outcome odds ratio (OR) = 2.33, 95% confidence interval (CI) = 1.41-3.86, and OR = 2.17, 95% CI = 1.30-3.38, respectively, death (OR = 6.63, 95% CI = 3.25-13.54, and OR = 3.13, 95% CI = 1.56-6.27, respectively), and sICH (OR = 3.02, 95% CI = 1.68-5.43, and OR = 1.89, 95% CI = 1.04-3.43, respectively), whereas baseline hyperglycemia did not.
Hyperglycemia (≥8.0 mmol/l) during 48 h after intravenous thrombolysis of ischemic stroke is strongly associated with unfavorable outcome, sICH, and death.
Objective
To evaluate the impact of extensive baseline ischemic changes on functional outcome after thrombolysis of basilar artery occlusion (BAO), and to study the effect of time to treatment in the ...absence of such findings.
Methods
We prospectively evaluated 184 consecutive patients with angiography‐proven BAO. The majority of patients received intravenous alteplase and concomitant full‐dose heparin. Extensive baseline ischemia was defined as posterior circulation Acute Stroke Prognosis Early CT score (pc‐ASPECTS) < 8. Onset‐to‐treatment time (OTT) was evaluated both as a continuous and as a categorical variable (0–6 hours, 6–12 hours, 12–24 hours, and 24–48 hours). Successful recanalization means thrombolysis in myocardial infarction (TIMI) = 2 to 3. Symptomatic intracranial hemorrhage (sICH) was evaluated with National Institute of Neurological Disorders and Stroke, European Cooperative Acute Stroke Study II, and Safe Implementation of Thrombolysis in Stroke criteria. Poor 3‐month outcome was defined as modified Rankin Scale score of 3 to 6.
Results
The majority (96%) of patients with baseline pc‐ASPECTS < 8 had poor 3‐month outcome, and a similar number (94%) was observed in those of them with confirmed recanalization (51.5%). In contrast, half of the patients with pc‐ASPECTS ≥ 8 and successful recanalization (73.2%) achieved good outcome. In these patients, OTT was associated with poor outcome neither as a continuous nor as a categorical variable. Factors independently associated with poor outcome were greater age and baseline National Institutes of Health Stroke Scale, lack of recanalization, history of atrial fibrillation, and sICH. In the model including the whole cohort (patients with any pc‐ASPECTS), pc‐ASPECTS < 8 was independently associated with poor outcome (odds ratio = 5.83, 95% confidence interval = 1.09–31.07).
Interpretation
In the absence of extensive baseline ischemia, recanalization of BAO up to 48 hours was seldom futile and produced good outcomes in 50% of patients, which was independent of time to treatment. ANN NEUROL 2013;73:688–694
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