Background
Sleep-disordered breathing (SDB) is frequent in stroke patients and negatively affects stroke outcomes. Positive airway pressure (PAP) is the standard first-line treatment for patients ...with moderate-to-severe SDB. Despite a strong link between PAP adherence and therapeutic response, rates of post-stroke PAP adherence remain underexplored. Our study aimed to determine PAP adherence in patients undergoing comprehensive sleep apnea assessment and in-lab PAP titration in the early subacute phase of stroke.
Methods
In-hospital screening pulse oximetry was performed in consecutive patients with imaging-confirmed acute ischemic stroke. Subjects with desaturation index ≥ 15.3/h were selected as PAP candidates, and polysomnography was recommended. In a sleep laboratory setting, subjects underwent a diagnostic night followed by a titration night, and PAP therapy was initiated in subjects with apnea–hypopnea index ≥ 15/h. Adherence to PAP therapy was assessed at a 6-month follow-up visit.
Results
Of 225 consecutive patients with acute ischemic stroke, 116 were PAP candidates and 52 were able to undergo polysomnography. PAP therapy was initiated in 35 subjects. At a 6-month follow-up visit, out of 34 stroke survivors, PAP adherence (PAP use of > 4 h per night) was present in 47%. Except for the significantly lower minimal nocturnal O
2
saturation determined from the polysomnography (74.6 ± 11.7% vs. 81.8 ± 5.2%,
p
= 0.025), no other significant difference in characteristics of the groups with PAP adherence and PAP non-adherence was found.
Conclusions
Less than half of the stroke subjects remained adherent to PAP therapy at 6 months post-PAP initiation. Special attention to support adaptation and adherence to PAP treatment is needed in this group of patients.
A substantial proportion of patients with ischemic stroke present with mild neurological deficits ('Stroke with mild symptoms,' SMS). Treating these patients with thrombolysis or with thrombectomy is ...controversial and clinical practice is different. We will highlight the importance of these treatment decisions by reviewing the recent advances in this area.
Intravenous thrombolysis with recombinant tissue plasminogen activator in patients with SMS showed a significant reduction in functional disability after 3 months. Treatment with tenecteplase seems to be a pharmacologically superior and possibly safer thrombolytic agent making it ideal for use in this patient group. Imaging criteria to select the profiting patients are evolving. Thrombectomy in patients with a large vessel occlusion and minor deficits are showing promising results in cohort studies so far, however, randomized controlled trials are lacking.
Patients with acute ischemic stroke and minor or rapidly improving symptoms should be carefully treated the same way as more severe strokes are treated as neurological deterioration is not infrequent. Nevertheless, treatment decisions should be individualized dependent on clinical and radiological features.
Sleep-disordered breathing (SDB) is present in more than 70% of stroke patients. Despite its association with increased morbidity, mortality, and reduced functional outcomes, targeted assessment of ...SDB in stroke patients, remain controversial. Polysomnography (“gold standard” examination) is a technically demanding and costly test with limited availability. The use of screening questionnaires is limited due to low specificity and sensitivity. Pulse oximetry seems to be a sensible alternative. Our study aimed to assess the feasibility and predictive value of routine pulse oximetric screening for assessment of SDB in patients with acute stroke.
Patients with acute stroke were enrolled in an open, prospective study. A single-night pulse oximetric assessment was used for SDB screening. Subsequently, polysomnography was performed to confirm SDB. Moderate-to-severe SDB was defined as apnea-hypopnea index ≥15.
Out of 420 enrolled patients, refusal to undergo examination was reported in 4 and non-cooperation during the investigation in 21 subjects. The area under the curve in a receiver operating curve to predict moderate-to-severe SDB by desaturation index (DI) was 0.86 (95% CI: 0.76–0.97), and optimal DI cut-off by Youden index was 15.3. Positive pulse oximetric screening (DI ≥ 15.3) had 90.5% sensitivity and 75% specificity to predict moderate-to-severe SDB.
Our results suggest a good adherence of acute stroke patients to the pulse oximetric screening. Pulse oximetry represents a simple, cost-effective, and sensitive examination that might be used in stroke patients as an appropriate tool for further selection for targeted diagnostic and therapeutic processes of SDB in the sleep laboratory.
•Routine pulse oximetry is feasible in acute stroke patients.•Pulse oximetry represents sensitive screening for sleep apnea in acute stroke.•Positive pulse oximetric screening was present in 49.2% of acute stroke patients.
Despite its high prevalence and negative impact, sleep-disordered breathing (SDB) remain commonly underdiagnosed and undertreated in stroke subjects. Multiple stroke comorbidities and risk factors, ...including obesity, hypertension, diabetes mellitus, ischemic heart disease, atrial fibrillation, and heart failure (H.F.) have been associated with SDB. This study aimed to examine associations of clinical and demographic characteristics with moderate-to-severe SDB (msSDB) in stroke patients and to develop a predictive score.
Consecutive patients with ischemic stroke were enrolled in an open, prospective study. SDB was assessed using standard polysomnography. Clinical and demographic characteristics, as well as findings from echocardiography, entered the analysis. Multivariate logistic regression models were used to examine the associations with msSDB. Based on the results, an original score to predict msSDB was proposed and tested.
120 patients with acute ischemic stroke (mean age: 64.0 ± 12.2 years, median NIHSS: 4) were included. Body-mass index (BMI), wake-up stroke onset (WUS), and diastolic dysfunction were independently associated with msSDB. A score allocating 1 point for BMI≥25 kg/m2 and <30 kg/m2, 2 points for BMI≥30 kg/m2, 1 point for WUS and 1 point for diastolic dysfunction resulted in an area under the curve of 0.81 (95% CI 0.71–0.90, p<0.001), sensitivity 82.9%, specificity 71.9% to identify stroke patients with msSDB.
BMI, WUS, and diastolic dysfunction were associated with msSDB. A simple score might help to identify acute stroke patients with msSDB, who are usual candidates for positive airway pressure therapy.
•Score might help to identify stroke patients with moderate-to-severe sleep apnea.•These patients are usual candidates for positive airway pressure therapy.•Body-mass index, wake-up stroke onset and diastolic dysfunction determine the score.•Score has slightly higher accuracy for obstructive rather than central sleep apnea.
Autonomic nervous system changes have been associated with outcome after intracerebral hemorrhage (ICH) previously. We aimed to investigate the association of heart rate entropy (HRE) with mortality ...after ICH.
Sample HRE, heart rate variability and baroreflex sensitivity were examined in consecutive ICH patients. Hematoma volume, intraventricular hemorrhage, infratentorial origin, consciousness impairment and age were combined into standard ICH score.
In 47 patients suffering ICH (mean age 61 years, median hemorrhage volume 38 mL) the areas under the curve (AUC) for mortality were 0.86, 0.83, 0.76, 0.74, 0.72 and 0.7 for HRE, ICH-score, normalized low frequency powers, low frequency/high frequency powers ratio, normalized high frequency powers and BRS, respectively. HRE and ICH score were associated with mortality independently (adjusted odd ratio (aOR) 0.09, 95% confidence interval (CI) 0.1–0.8, p = .03 and aOR 2.6, CI 1.03–6.6, p = .04). Combining ICH score with HRE into a novel score resulted in an AUC of 0.94, CI 0.88–0.99, p < .001.
Compared to several autonomic markers HRE seems to bear the largest amount of information on death probability after ICH. Moreover, HRE may predict mortality comparable to ICH score. Combining HRE with ICH score may increase the predictive performance for mortality after ICH.
•Heart rate entropy bears independent information on death probability after ICH.•Combining heart rate entropy with standard ICH score may increase the predictive performance for mortality after ICH.
Current guidelines for spontaneous intracerebral hemorrhage (ICH) recommend maintaining cerebral perfusion pressure (CPP) between 50 and 70 mmHg, depending on the state of autoregulation. We ...continuously assessed dynamic cerebral autoregulation and the possibility of determination of an optimal CPP (CPPopt) in ICH patients. Associations between autoregulation, CPPopt and functional outcome were explored.
Intracranial pressure (ICP), mean arterial pressure (MAP) and CPP were continuously recorded in 55 patients, with 38 patients included in the analysis. The pressure reactivity index (PRx) was calculated as moving correlation between MAP and ICP. CPPopt was defined as the CPP associated with the lowest PRx values. CPPopt was calculated using hourly updated of 4 hour windows. The modified Rankin Scale (mRS) was assessed at 3 months and associations between PRx, CPPopt and outcomes were explored using Pearson correlation and Fisher's exact test. Multivariate stepwise logistic regression models were calculated including standard outcome predictors along with percentage of time with PRx >0.2 and percentage of time within the CPPopt range.
An overall PRx indicating impairment of pressure reactivity was found in 47% of patients (n = 18). The mean PRx and the time spent with a PRx > 0.2 significantly correlated with mRS at 3 months (r = 0.50, P = 0.002; r = 0.46, P = 0.004). CPPopt was calculable during 57% of the monitoring time. The median CPP was 78 mmHg, the median CPPopt 83 mmHg. Mortality was lowest in the group of patients with a CPP close to their CPPopt. However, for none of the CPPopt variables a significant association to outcome was found. The percentage of time with impaired autoregulation and hemorrhage volume were independent predictors for acceptable outcome (mRS 1 to 4) at three months.
Failure of pressure reactivity seems common following severe ICH and is associated with unfavorable outcome. Real-time assessment of CPPopt is feasible in ICH and might provide a tool for an autoregulation-oriented CPP management. A larger trial is needed to explore if a CPPopt management results in better functional outcomes.
Sleep disordered breathing (SDB) is a frequent comorbidity in stroke patients. SDB is one of the independent risk factors for ischemic stroke. Conversely, stroke may contribute to SDB onset or ...aggravate premorbid SDB. Multiple mechanisms underlying SDB might be responsible for the development of stroke. The aim of this study was to compare polysomnographic, clinical, and laboratory characteristics of wake-up (WUS) and non-wake-up acute ischemic strokes (NWUS).
We prospectively enrolled 88 patients with acute ischemic stroke. Clinical characteristics of the population were recorded on admission, and blood samples were obtained in the fasting condition following morning. SDB was assessed using standard overnight polysomnography in the acute phase of the stroke.
WUS were present in 16 patients (18.2%), and NWUS in 72 patients (81.8%). In WUS compared to NWUS, we observed significantly higher values of apnea-hypopnea index (24.8 vs. 7.6, p = 0.007), desaturation index (DI 26.9 vs. 8.8, p = 0.005), arousal index (22.6 vs. 13.1, p = 0.035), diastolic blood pressure (91.6 mm Hg vs. 85.2 mm Hg, p = 0.039), triglyceride levels (TG 1.9 mmol/L vs. 1.2 mmol/L, p = 0.049), and significantly lower levels of D-dimer (0.4 μg/L vs. 0.7 μg/L, p = 0.035). DI (CI: 1.003-1.054, p = 0.031) and TG (CI: 1.002-1.877, p = 0.049) were the only independent variables significantly associated with WUS in binary logistic regression model.
Although the design of our study does not prove the causal relationship between SDB and WUS, higher severity of SDB parameters in WUS supports this hypothesis.
A commentary on this article appears in this issue on page 467.
and purpose: It is unclear whether intravenous thrombolysis (IVT) outperforms early dual antiplatelet therapy (DAPT) in the acute setting of mild ischemic stroke. The aim of this study was to compare ...early safety and efficacy of IVT to DAPT.
Data of mild non-cardioembolic stroke patients with admission NIHSS <=3 who received IVT or early DAPT in the period 2018-2021 were extracted from a nationwide, prospective stroke unit registry. Study endpoints included symptomatic intracerebral hemorrhage (sICH), early neurological deterioration ≥4 NIHSS points (END), and 3-months functional outcome by modified Rankin Scale (mRS).
1195 mild stroke patients treated with IVT and 2625 treated with DAPT were included. IVT patients were younger (68.1 versus 70.8 years), had less hypertension (72.8% versus 83.5%), diabetes (19% versus 28.8%) and history of myocardial infarction (7.6% versus 9.2%) and slightly higher admission NIHSS scores (median 2 versus median 1) as compared to DAPT patients. After propensity score matching and multivariable adjustment, IVT was associated with sICH (4 (1.2%) vs 0), END (aOR 2.8, CI 1.1-7.5), and there was no difference in mRS 0-1 at 3 months (aOR 1.3, CI 0.7-2.6).
This analysis from a prospective nationwide stroke unit network indicates that IVT is not superior to DAPT in the setting of mild non-cardioembolic stroke and may eventually be associated with harm. Further research focusing on acute therapy of mild stroke is highly warranted.
This study provides Class III evidence that IVT is not superior to dual antiplatelet therapy in patients with acute mild (NIHSS<=3) non-cardioembolic stroke. The study lacks the statistical precision to exclude clinically important superiority of either therapy.
Autonomic imbalance as measured by heart rate variability (HRV) has been associated with poor outcome after stroke. Observations on HRV changes in intracerebral hemorrhage (ICH) are scarce. Here, we ...aimed to investigate HRV in ICH as compared to a control group and to explore associations with stroke severity, hemorrhage volume and outcome after ICH.
We examined the autonomic modulation using frequency domain analysis of HRV during the acute phase of the ICH and in a healthy age- and hypertension-matched control group. Hematoma volume, intraventricular extension, initial stroke severity and baseline demographic, clinical parameters as well as mortality and functional outcome were included in the analysis.
47 patients with ICH and 47 age- and hypertension matched controls were analyzed. ICH patients showed significantly lower total high frequency band (HF) and low frequency band (LF) powers (p = 0.01, p < 0.001), higher normalized HF power (p = 0.03), and lower LF/HF ratio (p < 0.001) as compared to the controls. Autonomic parameters showed associations with stroke severity (p = 0.004) and intraventricular involvement (p = 0.01) and predicted poor outcome independently (p = 0.02).
Autonomic changes seems to be present in acute ICH and are associated with poor outcome independently. This may have future monitoring and therapeutic implications.
•Changes in HRV in ICH patients point toward overall decreased autonomic modulation with a shift toward parasympathetic dominance•Autonomic measurements show associations with stroke severity and predict poor outcome independently•Autonomic parameters may have future monitoring and therapeutic implications in ICH
Numerous studies have investigated the influence of meteorologic factors and seasons on the incidence of spontaneous intracerebral hemorrhage (ICH) with ambiguous results. In the present study, data ...from a large, international multicenter trial in patients with ICH were used to identify seasonal and meteorologic determinants for hypertensive-ICH with greater applicability.
Patients were grouped according to the presumptive ICH cause, that is, hypertensive when located in the basal ganglia brain stem as well as cerebellum and nonhypertensive when located lobar. Both groups were compared with regard to air temperature and air pressure and their occurrence during the year. A regression analysis was performed to identify independent predictors of hypertensive-ICH.
Only hypertensive-ICH showed a seasonal pattern and occurred with higher air pressure values and at younger age. Independent predictors of hypertensive-ICH were increased air pressure on the actual day of the event and younger age as well as higher temperature.
In the present study with an international cohort, besides age air pressure, more than temperature, had an influence on the occurrence of hypertensive-ICH, only.
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