Purpose: The aim of this study was to determine the long‐term case fatality of patients with a first episode of status epilepticus (SE group) of cerebrovascular etiology, as compared with that in ...acute stroke patients without SE (AS group).
Methods: Patients with SE who had been prospectively admitted to an epidemiologic study were retrospectively compared with a cohort of patients from the local stroke registry. The main outcome end point was overall survival. Survival curves were generated according to the Kaplan–Meier method and compared by using the log‐rank test. An extended Cox model was used to examine the impact of patient group on the risk of death. Covariates considered potential confounders included age at diagnosis, sex, type of stroke, affected hemisphere, and localization of lesions.
Results: Of 166 patients who entered the study, 93 patients were in the SE group, and 73 patients were in the AS group; 53 SE patients and 35 AS patients died during the study. Patient group (SE vs. AS) showed no significant impact on survival (p = 0.0832) in univariate analysis. In contrast, the results from a multivariable analysis suggest that after 6 months, patients with SE were at about twice the risk of death as were patients with AS hazard ratio of 2.12 with 95% confidence interval, 1.04–4.32, p = 0.0392.
Conclusions: The occurrence of SE in patients with cerebrovascular disease indicates a high risk of death within 3 years. In contrast, the case fatality risk attributable to recurrent status or seizures is lower.
Background
Telemedicine may facilitate the selection of stroke patients who require emergency transfer to a comprehensive stroke center to receive additional therapies other than intravenous tissue ...plasminogen activator.
Aims and/or hypothesis
We sought to analyze frequency, patient characteristics, and specific therapies among emergently transferred patients within the telemedical Stroke East Saxony Network.
Methods
We reviewed consecutive patients who were transferred emergently from remote spoke sites to hub sites. Certified stroke neurologists performed teleconsultations 24/7, with access to high-speed videoconferencing and transfer of brain images. Emergent transfers were initiated when considered necessary by the stroke neurologist.
Results
In 2009 and 2010, we conducted 1413 teleconsultations and subsequently recommended transfer in 339 (24%) patients mean age 64 ± 14 years, 54% males, median National Institutes of Health Stroke Scale score 5 (interquartile range, IQR 12). The mean teleconsultation-to-arrival time was 1·7 ± 0·8 h (median 1·6 h). Sixty-eight (20%) transferred patients had a nonstroke diagnosis. The remaining 271 (80%) patients had stroke diagnoses ischemic stroke, 114 (34%); transient ischemic attack, 8 (2%); and intracranial haemorrhage, 149 (44%). Forty (35%) ischemic stroke patients received tissue plasminogen activator at spoke sites (‘drip and ship’). Of the 240 stroke patients emergently transferred to the main hub site, 119 (49·6%) received at least one specific stroke therapy.
Conclusion
A remarkable number of stroke patients can be transferred within a telemedical network to enable the delivery of specific stroke therapies that require advanced multispecialty expertise. Whether associated logistic efforts and costs have an impact on patients' clinical outcomes needs to be evaluated.
Focal cerebral ischemic lesions demonstrate a gradual reduction of blood flow from the rim to the core. Flow reduction induces irreversible damage in the core region, whereas more peripheral tissue, ...i.e. penumbral tissue, is applicable to therapeutic interventions. Secondary mechanisms for lesion growth involve excitotoxicity, extracellular ion shifts, lactate generation, tissue acidosis, inflammation, spreading depolarization and many other processes. These toxic mediators accumulate in the ischemic core and endanger the still viable rim by diffusion or other spreading-like mechanisms, probably in part largely independent from blood flow. A substantial proportion of hemodynamic penumbral tissue could be demonstrated both in experimental settings and in clinical practice, whereas the precise spatial and temporary contribution of secondary mechanisms is much more difficult to investigate in our patients. Diffusion or spreading-mediated neurotoxicity will affect a small rim around the necrotic lesion. Due to the third power of volumetric analysis this would contribute to a large amount in small experimental lesions, but to a negligible amount of tissue in large clinical lesions and could therefore explain the difference in efficacy of neuroprotective strategies between experimental and clinical setups. Therefore, we discuss the likelihood of direct flow-dependent versus diffusion- or spreading-mediated impairment of endangered tissue in focal cerebral ischemia.
Lesion evolution in cerebral ischemia BACK, Tobias; HEMMEN, Thomas; SCHÜLER, Olaf G
Journal of neurology,
04/2004, Letnik:
251, Številka:
4
Journal Article
Recenzirano
There is sound evidence from histopathological and magnetic resonance imaging (MRI) studies that focal ischemic brain lesions tend to increase in size over time. Considerable lesion growth was ...observed in models of animal stroke as well as in patients presenting with hemispheric stroke. In focal cerebral ischemia, lesions predominantly enlarge early within 12 hours after onset. Ischemic injury is caused by complete necrosis in most of the affected tissue. By contrast, in global cerebral ischemia as seen after cardiac arrest, lesions appear late (>12 h) in selectively vulnerable brain regions such as the hippocampus, and neurons are damaged by apoptotic cell death. The high and regionally distinct vulnerability of the brain explains why prolonged periods of global ischemia result in widespread loss of energy metabolites combined with diffuse brain edema and global damage. Postulated mechanisms involved in lesion growth include among others excitotoxicity, periinfarct depolarizations, lactacidosis, microcirculatory disturbances, and flow-metabolism uncoupling. Research in the field faces two main challenges. First,maturation phenomena of injury may require special imaging techniques to detect early ischemic changes. Second, the dynamic nature of the changes underlines the need to conduct longitudinal studies with a variety of imaging techniques (e. g., metabolic imaging, diffusion/perfusion MRI, positron emission tomography) that require a differentiated interpretation of the alterations observed.
Previous magnetic resonance (MR) investigations of middle cerebral artery (MCA) occlusion in rats were limited by the lack of early post-occlusion MR measurements and/or electrophysiological ...monitoring. Therefore, we have developed a technique which allows to perform MCA occlusion inside the magnet under simultaneous recording of EEG and direct current (DC) potentials for monitoring the ischemic insult. Rats underwent intraluminal thread occlusion of the right MCA inside the MR tomograph via a catheter extension device, while EEG and DC potentials were recorded by non-magnetic graphite electrodes. The thread was slowly advanced until electrophysiological changes appeared. Diffusion-weighted MR images (DWI) were obtained before and repeatedly after MCA occlusion for up to 7 h. Thereafter, rat brains were frozen in situ or fixed by transcardiac perfusion and investigated by biochemical and histological techniques. In 15 of 18 animals (83%), MCA thread insertion caused immediate EEG changes and a negative DC potential shift at 4.4 ± 1.8 min (mean ± SD) after occlusion. In all animals with electrophysiological changes, signal intensity of DWI began to increase within the MCA territory at 12–14 min post-occlusion (the end of the first measurement), and continued to rise throughout the observation period. Ischemia was confirmed by demonstrating focal areas of energy depletion on ATP images. In the animals without electrophysiological changes, DWI or biochemical alterations were absent or confined to the central part of caudate-putamen. The histological lesion area of successfully occluded animals amounted to 70.1 ± 5.8% of the ipsilateral hemisphere at the level of caudate-putamen. Our observations demonstrate that intraluminal thread occlusion of the rat MCA can be performed inside the magnet but has to be supplemented by electrophysiological recording to ascertain correct positioning of the occluding device.
To study the timecourse of health-related global and domain-specific quality of life (QOL) in patients presenting with stroke or transient ischemic attacks (TIA) up to one year after the ischemic ...event. Variables were identified that may predict poststroke life satisfaction.
In this prospective study, a cohort of 183 stroke/TIA patients was followed up at 3, 6, and 12 months. A total of 144 survivors completed the follow-up (65 women, 79 men, mean age 65.3 years). Health-related QOL was assessed by the Short Form 36 (SF-36) questionnaire, the neurological status by the European Stroke Scale (ESS). Disability was evaluated by using the Barthel index and the modified Swedish Stroke Registry Follow-up Form; depression was scored by the Montgomery-Asberg Depression Rating Scale (MADRS).
One year after stroke/TIA, 66 % of patients reported a worsening of life satisfaction compared with the prestroke level. The SF-36 physical component summary was reduced throughout the observation period. The SF-36 mental component summary deteriorated between the 6- and 12-months follow-up from 52.2 +/- 7.1 to 50.6 +/- 7.1 (p < 0.05). The SF-36 domains "physical functioning", "social functioning" and the MADRS scores both showed a significant deterioration between 6 and 12 months poststroke (p < 0.05). In contrast, the neurological status and the degree of disability remained stable. Male sex, absence of diabetes, and normal MADRS scores at 3 and 6 months postinsult were identified as predictors of favorable QOL after 1 year (p < 0.05).
Despite stable neurologic function and disability, global as well as domain-specific measures of QOL deteriorated over the 12-months observation period in a cohort of stroke survivors.
Abstract Objectives Stroke unit care has been shown to be beneficial but costly. In an own previous study, the resource utilization of stroke unit care has been evaluated. Since the resource ...utilization on regular neurological wards is widely unknown, we determined the costs for acute stroke care on regular neurological wards to compare both treatment settings. Methods and patients We included 253 consecutive in-patients with the diagnosis of ischemic stroke (IS), intracerebral hemorrhage (ICH) or transient ischemic attack (TIA) treated on regular wards at a German University Department of Neurology, between 1 January and 30 June 1998. The modified Rankin scale (mRS) was used to assess outcome. Costs of stroke care were calculated from the perspective of the healthcare provider (hospital) by using a bottom-up approach. Resource utilization was compared to stroke unit care as determined in a previous study. Prices of 2002 were used (in Euros). Results IS was present in 78% ( n = 196), TIA in 13% ( n = 34), and ICH in 9% ( n = 23) of patients. Length of stay was 11.1 ± 8.9 (mean ± S.D., IS), 11.1 ± 6.5 (TIA), and 16.9 ± 15.5 (ICH) days ( p > 0.05). Mean costs of stroke care were €3060 (US$ 3180) for TIA, € 3070 (US$ 3200) for IS and € 5210 (US$ 5430) for ICH ( p < 0.05, ICH versus IS and TIA). The highest costs were due to non-medical care (46%) and personnel (25%). The mRS improved during hospitalization from 3.0 ± 1.6 to 2.2 ± 1.8 ( p < 0.01). Compared to care on regular neurological wards, mean costs per admission with treatment on stroke units increased by 7.0%, mean costs per day by 15.6%. Conclusion The comparison – considering a potential bias of patient selection – shows that acute stroke unit care is approximately 16% more costly than treatment on regular neurological wards due to higher resource use of personnel and diagnostic procedures. Stroke unit treatment tends to decrease post-acute in-patient care costs.
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