Management of stroke with minor symptoms may represent a therapeutical dilemma as the hemorrhage risk of acute thrombolytic therapy may eventually outweigh the stroke severity. However, around 30% of ...patients presenting with minor stroke symptoms are ultimately left with disability. The objective of this review is to evaluate the current literature and evidence regarding the management of minor stroke, with a particular emphasis on the role of IV thrombolysis. Definition of minor stroke, pre-hospital recognition of minor stroke and stroke of unknown onset are discussed together with neuroimaging aspects and existing evidence for IV thrombolysis in minor strokes. Though current guidelines advise against the use of thrombolysis in those without clearly disabling symptoms due to a paucity of evidence, advanced imaging techniques may be able to identify those likely to benefit. Further research on this topic is ongoing.
OBJECTIVES:Autonomic impairment after acute traumatic brain injury has been associated independently with both increased morbidity and mortality. Links between autonomic impairment and increased ...intracranial pressure or impaired cerebral autoregulation have been described as well. However, relationships between autonomic impairment, intracranial pressure, impaired cerebral autoregulation, and outcome remain poorly explored. Using continuous measurements of heart rate variability and baroreflex sensitivity we aimed to test whether autonomic markers are associated with functional outcome and mortality independently of intracranial variables. Further, we aimed to evaluate the relationships between autonomic functions, intracranial pressure, and cerebral autoregulation.
DESIGN:Retrospective analysis of a prospective database.
SETTING:Neurocritical care unit in a university hospital.
SUBJECTS:Sedated patients with severe traumatic brain injury.
MEASUREMENTS AND MAIN RESULTS:Waveforms of intracranial pressure and arterial blood pressure, baseline Glasgow Coma Scale and 6 months Glasgow Outcome Scale were recorded. Baroreflex sensitivity was assessed every 10 seconds using a modified cross-correlational method. Frequency domain analyses of heart rate variability were performed automatically every 10 seconds from a moving 300 seconds of the monitoring time window. Mean values of baroreflex sensitivity, heart rate variability, intracranial pressure, arterial blood pressure, cerebral perfusion pressure, and impaired cerebral autoregulation over the entire monitoring period were calculated for each patient. Two hundred and sixty-two patients with a median age of 36 years entered the analysis. The median admission Glasgow Coma Scale was 6, the median Glasgow Outcome Scale was 3, and the mortality at 6 months was 23%. Baroreflex sensitivity (adjusted odds ratio, 0.9; p = 0.02) and relative power of a high frequency band of heart rate variability (adjusted odds ratio, 1.05; p < 0.001) were individually associated with mortality, independently of age, admission Glasgow Coma Scale, intracranial pressure, pressure reactivity index, or cerebral perfusion pressure. Baroreflex sensitivity showed no correlation with intracranial pressure or cerebral perfusion pressure; the correlation with pressure reactivity index was strong in older patients (age, > 60 yr). The relative power of high frequency correlated significantly with intracranial pressure and cerebral perfusion pressure, but not with pressure reactivity index. The relative power of low frequency correlated significantly with pressure reactivity index.
CONCLUSIONS:Autonomic impairment, as measured by heart rate variability and baroreflex sensitivity, is significantly associated with increased mortality after traumatic brain injury. These effects, though partially interlinked, seem to be independent of age, trauma severity, intracranial pressure, or autoregulatory status, and thus represent a discrete phenomenon in the pathophysiology of traumatic brain injury. Continuous measurements of heart rate variability and baroreflex sensitivity in the neuromonitoring setting of severe traumatic brain injury may carry novel pathophysiological and predictive information.
Autonomic dysfunction, including increased sympathetic drive and blunted baroreflex, has repeatedly been observed in acute stroke. Of clinical importance is that the stroke-related autonomic ...imbalance seems to be linked to worse outcome after stroke. Here, we discuss the role of baroreflex impairment in acute stroke and its possible pathophysiological and therapeutic relevance. Summary of Review- Possible mechanisms linking baroreflex impairment with unfavorable outcome in stroke may include increased cardiovascular morbidity and mortality, promotion of secondary brain injury due to local inflammation, hyperglycemia, or altered cerebral perfusion.
We suggest therefore that the modifying of autonomic functions may have important therapeutic implications in acute ischemic as well as in hemorrhagic stroke.
The efficacy of recanalization treatment in patients with ischemic stroke due to large vessel occlusion (LVO) is highly time dependent. We aimed to investigate the effects of an optimization of ...prehospital and intrahospital pathways on time metrics and efficacy of endovascular treatment in ischemic stroke due to LVO.
Patients treated with mechanical thrombectomy (MT) at the Hospital of St. John of God Vienna, Austria, between 2013 and 2020 were extracted from the Austrian Stroke Unit Registry. Study endpoints including time metrics, early neurological improvement and functional outcome measured by modified Rankin Scale (mRS) at 3 months were compared before and after optimization of prehospital and intrahospital pathways.
Two hundred ninety-nine patients were treated with MT during the study period, 94 before and 205 after the workflow optimization. Workflow optimization was significantly associated with time metrics improvement (door to groin puncture time 45 versus 31 min; p < 0.001), rates of neurological improvement (NIHSS ≥ 8: 30 (35%) vs. 70 (47%), p = 0.04) and radiological outcome (TICI ≥ 2b: 71 (75%) versus 153 (87%); p = 0.013). Functional outcome (mRS 0-2: 17 (18%) versus 57 (28%); p = 0.067) and mortality (34 (37%) versus 54 (32%); p = 0.450) at 3 months showed a non-significant trend in the later time period group.
The implementation of workflow optimization was associated a significant reduction of intrahospital time delays and improvement of neurological and radiological outcomes.
To investigate the influence of cerebral atrophy on clinical outcome in patients with supratentorial intracerebral hemorrhage.
Computed tomography scans of 320 patients included in a prospective, ...multicenter trial were used for a segmentation analysis to determine the supratentorial cerebral volume. A logistic regression analysis was used to explore its effect on outcome after 90 days in addition to other clinical and imaging parameters.
Cerebral volume loss significantly reduced the odds for favorable outcome after 90 days (odds ratio=0.91; confidence interval, 0.85-0.99; P=0.02).
Cerebral atrophy is an independent predictor of unfavorable outcome after intracerebral hemorrhage, indicating reduced functional recovery potential in these individuals.
Abstract Background Autonomic dysfunction is a substantial part of extrapyramidal diseases, including Parkinson's disease (PD). Baroreflex is an important determinant of short-term blood pressure ...regulation and cardiovascular variability. Impaired baroreflex sensitivity (BRS) in PD has been a subject of investigation in several studies, however the relationship between BRS and orthostatic hypotension (OH) is still poorly understood. Objective To compare the BRS of Parkinson's disease patients with those of an age-matched control population, and to determine BRS association with blood pressure, orthostatic hypotension and antiparkinson treatment. Patients and methods The study included 52 patients with Parkinson's disease and 52 controls. We assessed autonomic dysfunction with a Finometer device using the method of spontaneous fluctuations of blood pressure (BP) and the R-R interval in time domain, expressed as baroreflex sensitivity. Supine and standing blood pressure were measured under standard conditions. Results BRS values were significantly lower in the PD group as compared to the control group: 4.0 ± 2.0 vs. 6.4 ± 3.8 ms/mmHg (p = 0.001). We determined a significant correlation between decreased BRS values and increased systolic BP (p = 0.003) as well as between decreased BRS values and orthostatic hypotension (OH), in the PD group (p = 0.048). Moreover, patients with PD and OH had significantly lower BRS as compared with patients with PD without OH (3.2 ± 2 versus 4.5 ± 2, p = 0.045). We also determined that BRS values were significantly lower in the PD population treated with LDOPA + COMTI as compared to the LDOPA + COMTI untreated patients (3.0 ± 1.5 vs. 4.8 ± 2.0, p < 0.001). Conclusion BRS was significantly lower in the PD group, supine hypertension and orthostatic hypotension was strongly associated with low BRS. We determined for the first time that orthostatic hypotension strongly correlates with decreased baroreflex sensitivity in PD patients. Moreover, orthostatic hypotension was associated with low BRS not only qualitatively but also quantitatively. We also revealed a strong association between LDOPA + COMTI therapy and decreased BRS in the literature for the first time.
Common consequences following aneurysmal subarachnoid hemorrhage (aSAH) are cerebral vasospasm (CV), impaired cerebral autoregulation (CA), and disturbance in the autonomic nervous system, as ...indicated by lower baroreflex sensitivity (BRS). The compensatory interaction between BRS and CA has been shown in healthy volunteers and stable pathological conditions such as carotid atherosclerosis. The aim of this study was to investigate whether the inverse correlation between BRS and CA would be lost in patients after aSAH during vasospasm. A secondary objective was to analyze the time-trend of BRS after aSAH.
Retrospective analysis of prospectively collected data was performed at the Neuro-Critical Care Unit of Addenbrooke's Hospital (Cambridge, UK) between June 2010 and January 2012. The cerebral blood flow velocity (CBFV) was measured in the middle cerebral artery using transcranial Doppler ultrasonography (TCD). The arterial blood pressure (ABP) was monitored invasively through an arterial line. CA was quantified by the correlation coefficient (Mxa) between slow oscillations in ABP and CBFV. BRS was calculated using the sequential cross-correlation method using the ABP signal.
A total of 73 patients with aSAH were included. The age median (lower-upper quartile) was 58 (50-67). WFNS scale was 2 (1-4) and the modified Fisher scale was 3 (1-3). In the total group, 31 patients (42%) had a CV and 42 (58%) had no CV. ABP and CBFV were higher in patients with CV during vasospasm compared to patients without CV (
= 0.001 and
< 0.001). There was no significant correlation between Mxa and BRS in patients with CV, neither during nor before vasospasm. In patients without CV, a significant, although moderate correlation was found between BRS and Mxa (r
= 0.31;
= 0.040), with higher BRS being associated with worse CA. Multiple linear regression analysis showed a significant worsening of BRS after aSAH in patients with CV (
= -0.42;
< 0.001).
Inverse compensatory correlation between BRS and CA was lost in patients who developed CV after aSAH, both before and during vasospasm. The impact of these findings on the prognosis of aSAH should be investigated in larger studies.
Background and purpose
According to evidence‐based clinical practice guidelines, patients presenting with disabling stroke symptoms should be treated with intravenous tissue plasminogen activator (IV ...tPA) within 4.5 h of time last known well. However, 25% of strokes are detected upon awakening (i.e., wake‐up stroke WUS), which renders patients ineligible for IV tPA administered via time‐based treatment algorithms, because it is impossible to establish a reliable time of symptom onset. We performed a systematic review and meta‐analysis of the efficacy and safety of IV tPA compared with normal saline, placebo, or no treatment in patients with WUS using imaging‐based treatment algorithms.
Methods
We searched MEDLINE, Web of Science, and Scopus between January 1, 2006 and April 30, 2020. We included controlled trials (randomized or nonrandomized), observational cohort studies (prospective or retrospective), and single‐arm studies in which adults with WUS were administered IV tPA after magnetic resonance imaging (MRI)‐ or computed tomography (CT)‐based imaging. Our primary outcome was recovery at 90 days (defined as a modified Rankin Scale mRS score of 0–2), and our secondary outcomes were symptomatic intracranial hemorrhage (sICH) within 36 h, mortality, and other adverse effects.
Results
We included 16 studies that enrolled a total of 14,017 patients. Most studies were conducted in Europe (37.5%) or North America (37.5%), and 1757 patients (12.5%) received IV tPA. All studies used MRI‐based (five studies) or CT‐based (10 studies) imaging selection, and one study used a combination of modalities. Sixty‐one percent of patients receiving IV tPA achieved an mRS score of 0 to 2 at 90 days (95% confidence interval CI: 51%–70%, 12 studies), with a relative risk (RR) of 1.21 compared with patients not receiving IV tPA (95% CI: 1.01–1.46, four studies). Three percent of patients receiving IV tPA experienced sICH within 36 h (95% CI: 2.5%–4.1%; 16 studies), which is an RR of 4.00 compared with patients not receiving IV tPA (95% CI: 2.85–5.61, seven studies).
Conclusions
This systematic review and meta‐analysis suggests that IV tPA is associated with a better functional outcome at 90 days despite the increased but acceptable risk of sICH. Based on these results, IV tPA should be offered as a treatment for WUS patients with favorable neuroimaging findings.
FiletPA may be an effective therapy for “Wake‐Up Stroke”. In this meta‐analysis, tPA was associated with an increased probability of achieving a good functional outcome at 90 days and with an acceptably low risk of intracranial hemorrhage.
Background The significance of white matter lesions (WMLs) in intracerebral hemorrhage (ICH) remains unclear. We investigated the effects of WML on initial hematoma volume, hematoma growth, ...intraventricular extension, and clinical outcome in patients with spontaneous ICH. Methods Computed tomography scans of 262 patients included in a placebo arm of a prospective, multicenter trial were used for a semi-quantitative analysis of white matter changes. A logistic regression analysis was used to explore the effects on hematoma volume, volume changes, intraventricular hemorrhage, and clinical outcome after 90 days. Results The degree of WML was not associated with initial hematoma volume, absolute and relative hematoma growth, hematoma growth >33% or >6 mL, or with intraventricular extension. WML significantly increased the odds for poor outcome after 90 days (adjusted OR 1.4, 95% CI 1.1-1.8, P = .02). Conclusions WMLs were not associated with initial hematoma volume, hematoma growth, or intraventricular extension. WMLs were associated with poor outcome independently.
PDF
