Mortality In Acute Stroke Patients Research Articles

Hospital mortality from atrial fibrillation associated with ischemic stroke: a national data report

Purpose: To study factors associated with poor outcomes in acute ischemic stroke patients with atrial fibrillation (AF) by using a national database. Materials and Methods: This study was a retrospective analytical study by retrieving data from the Thailand national database system for universal coverage (UC) health insurance system. All adult patients aged over 18 years who were admitted with acute ischemic stroke during the fiscal years 2004–2012 by the appropriate ICD codes were searched. Eligible patients with AF were categorized as alive or dead during hospital stay. The mortality rate and factors associated with in-hospital mortality were studied. Results: There were 522,699 patients diagnosed as acute stroke; 277,291 patients (53.1%) had acute ischemic stroke. Of those with ischemic stroke, 25,319 patients (9.1%) had AF. The mortality rates of acute ischemic stroke with AF were 14.1% and without AF were 6.2%, (p < 0.001). Significant factors associated with mortality in acute stroke patients with AF by multivariate logistic regression were female gender (adjusted odds ratio; AOR 1.28), co-morbid diseases such as diabetes (AOR 1.28), hypertension (AOR 1.26), rt-PA treatment (AOR 0.55), and stroke complications, such as pneumonia (AOR 2.60), septicemia (AOR 6.50), or gastrointestinal bleeding (AOR 2.16). Conclusions: At the national level, AF caused a higher mortality rate in acute ischemic stroke than in non-AF patients. Gender, co-morbid diseases, rt-PA treatment, and stroke complications were associated with mortality in acute ischemic stroke with AF.

Neutrophil Lymphocyte Ratio as a Predictor of Stroke

The aim of this study is to investigate the relationship of the neutrophil to lymphocyte ratio (NLR) with short-term mortality in acute stroke. This retrospective study included 255 patients with acute cerebral infarction who presented within 24 hours of symptom onset. A hemogram from peripheral venous blood samples was taken at the time of admission. The NLR was calculated as the ratio of neutrophils to lymphocytes. Duration of follow-up was defined as 60 days. Seventy-one of 255 patients died during the follow-up period. The median NLR was significantly increased among the mortality group compared with the survival group (median 11.50, interquartile ratio [IQR] 10.40 vs median 3.79, IQR 4.72; P = .001). In our multivariate Cox regression model, NLR >5.0 (hazard ratio [HR] 3.30; 95% confidence interval [CI] 1.35-8.07), National Institutes of Health Stroke Scale score (HR 1.11; 95% CI 1.07-1.16), glucose values at admission (HR 1.007; 95% CI 1.002-1.011), and history of coronary artery disease (HR 2.49; 95% CI 1.26-4.92) were predictors of short-term mortality. The sensitivity for short-term mortality when the NLR was >5 was 83.10%, and the specificity was 62.00%. The positive predictive value of a NLR >5 was 45.7%, and negative predictive value was 90.50%. A strong linear association between NLR and National Institutes of Health Stroke Scale score was also observed (r = 0.64; P = .001). In addition, the NLR was higher in both the atherosclerotic and cardioembolic stroke subgroups than the lacunar infarct subgroup (6.5 [IQR 7.2], 7.5 [IQR 8.9], and 3.20 [IQR 3.50], respectively; P = .001). The NLR at the time of hospital admission may be a predictor of short-term mortality in acute stroke patients. Because of the routine use and inexpensive nature of hemogram analysis, the NLR should be investigated in future prospective, randomized controlled trials investigating acute stroke.

High level of plasma adiponectin in acute stroke patients is associated with stroke mortality

We examined the association between plasma adiponectin (ADPN) levels and cardiovascular mortality in acute stroke patients. We enrolled 552 consecutive acute stroke patients. Measurements were made at baseline and the patients were followed prospectively. The primary endpoint was cardiovascular (stroke or ischemic heart disease) death and the secondary endpoint was all-cause death. During the median follow-up period of 17 months, 39 patients died, 15 being due to stroke. No patients died of ischemic heart disease. After adjustment for age, sex, presence of hypertension, diabetes mellitus, and hyperlipidemia, the highest tertile of ADPN level (> 11.7 μg/ml) was associated with stroke mortality (hazard ratio: 6.55, 95% confidence interval: 1.73–24.8), but not with all-cause mortality (hazard ratio: 1.89, 95% confidence interval: 0.95–3.77). High levels of plasma ADPN can be a predictor of stroke mortality during the 17 months following an episode of acute stroke in patients.

Serum Calcium Levels and Long-Term Mortality in Patients with Acute Stroke

Background: Calcium concentrations in serum are maintained within an exquisitely narrow range. Our aim was to examine the association between serum calcium and albumin-adjusted calcium (calcium_adj) levels and stroke outcome in a cohort of unselected patients with acute stroke. Methods: Consecutive patients hospitalized due to acute stroke (ischemic or intracerebral hemorrhage) throughout a large medical center were systematically assessed and followed for 1 year. Baseline total calcium and calcium_adj levels were collapsed into groups of low (<8.6 mg/dl), normal (8.7–9.9 mg/dl) and high (>10 mg/dl) levels and linear and quadratic relations with outcome were examined. Result: Among 784 patients (mean age 70.7 ± 12.5 years, 42.5% females), the mean ± SD total calcium level was 9.3 ± 0.6 mg/dl. For total calcium, the adjusted hazard ratio (HR) for all-cause death over 1 year was 1.83 [95% confidence interval (CI) 1.22–2.75] among patients with low versus normal levels. For calcium_adj, the adjusted HR for all-cause death among women was over 3-fold higher among patients with high calcium_adj levels versus those with normal levels (3.31; 95% CI 1.70–6.46), while no such associations were observed among men. In models developed to estimate the linear and quadratic relations, each unit increment in total calcium squared was associated with an increased adjusted HR of all-cause death over 1 year (p = 0.02) confirming nonlinear associations, and each unit increment in calcium_adj squared was associated with an increased adjusted HR of all-cause death over 1 year among women (p < 0.001) but not among men (p = 0.70). Conclusions: Serum calcium concentrations are a marker of mortality in acute stroke patients, but the associations are not linear, increasing at both extremes of calcium levels. Our findings suggest that long-term survival is optimal in a distinct range of serum calcium levels.

Comparison of carbamylated versus recombinant erythropoietin during spinal cord ischemia/reperfusion injury

We previously showed that erythropoietin (EPO) attenuates the morphological signs of spinal cord ischemia/reperfusion (I/R) injury in swine [1] without, however, improving neurological function. The clinical use of EPO has been cautioned most recently due to serious safety concerns arising from an increased mortality in acute stroke patients treated with EPO and simultaneously receiving systemic thrombolysis [2]. Carbamylated EPO (cEPO) is an EPO derivative without erythropoietic activity and devoid of the EPO side effects, but with apparently well maintained cytoprotective qualities [3]. We therefore tested the hypothesis whether cEPO may be equally efficient as EPO in reducing morphological as well as functional aortic occlusion-induced spinal cord I/R injury.

Serum and Cerebrospinal Fluid Magnesium Levels, Glasgow Coma Scores, and In-Hospital Mortality in Patients with Acute Stroke

The aim of this study was to determine the relationship between serum and cerebrospinal fluid (CSF) magnesium(Mg+2) levels, Glasgow Coma Scores (GCS), and 7-day mortality in acute stroke patients. Patients with acute ischemic or hemorrhagic stroke arriving within the first 3 h of symptoms were included in the study. The control group consisted of healthy volunteers. GCS was determined, and blood and CSF samples were taken in order to establish serum and CSF glucose, Mg+2, sodium, potassium, calcium, and chlorine levels.Mortality was recorded at 7 days after admission. CSF Mg+2 in the ischemic infarct group was significantly lower than in the control group (p=0.006). CSF Mg+2 in the ischemic infarct patients with a GCS < or = 8 were significantly lower (p=0.002) than controls and in ischemic infarct patients with a GCS > or = 9. In the ischemic stroke patients, CSF Mg+2 and GCS were significantly correlated (r=55, p=0.031). CSF Mg+2 levels in ischemic stroke patients who died within 7 days were significantly lower than controls, ischemic stroke patients who survived, and hemorrhagic stroke patients who died (p=0.002, p=0.042, and p=0.005,respectively). Low CSF Mg+2 levels in patients with acute ischemic stoke at admission predicted a higher 1-week mortality.

Mortality prediction in critical care for acute stroke: Severity of illness–score or coma–scale?

The use of early prognostic data provided by various scores in critically ill stroke patients remains unclear. We tested the performance of the Simplified Acute Physiology Score (SAPS) II in prediction of mortality of acute stroke patients in the NeuroCriticalCareUnit (NCCU). During one year every patient admitted to the NCCUs at 2 University hospitals for cerebral ischemia (CI) or intracerebral hemorrhage (ICH) and intubated was included in this study. Data for SAPS (I)/II and the Glasgow Coma Scale (GCS) were collected, and mortality at 10 days, 90 days and 1 year was determined. Prognostic performance of all scores was tested by calculation of receiver operating curve (ROC) and by Cox regression analysis. 90 patients were included in the study, 49 with ICH and 41 with CI. Mortality after 10 days was 32.2%, after 3 months 58.9% and after 1 year 67.8%. Compared by their area under curve the predictive values were overall quite good for both SAPS (I) (0.77) and SAPS II (0.77) as well as GCS. Motor subscore was equal to total GCS (0.75 vs. 0.73). In Cox regression models all three scores were independent predictors of fatal outcome. SAPS II and SAPS (I) but also the GCS are valuable tools for prediction of short and long-term mortality in acute stroke patients treated in NCCU. The GCS as a predictor for mortality in stroke patients could be further simplified by using its subscore "best motor response" alone.

Predictive value of white blood cell count on admission for in-hospital mortality in acute stroke patients

Objective: In the present study, we sought to determine the predictive value of white blood cell (WBC) count measured on admission for in-hospital death in acute stroke patients. Methods: WBC count was measured automatically in 400 consecutive acute stroke patients (67.5±12.9 years old; 226 female) on admission to hospital. Patients included into the study had symptoms starting less than 12 h prior to hospitalization and no known causes of inflammation. Logistic regression adjusted for age, gender, the presence of diabetes, hypertension, atrial fibrillation, previous stroke and ischemic heart disease was used for the calculation of odds ratio (OR) with 95% confidence interval (CI) for in-hospital mortality. Results: Stroke patients with WBC counts in the third tertile (over 9.7×10 3 μL −1) had more than eight times (OR: 8.26; 95% CI: 3.95–17.25; P<0.0001) increased risk of in-hospital mortality as compared with the rest of the patients. The WBC count increment of every 1000 cell/μL was associated with OR for in-hospital death of 1.27 (95% CI: 1.17–1.39; P<0.0001). There was also a significant correlation between patients’ WBC count and their clinical condition and degree of disability at the time of admission to hospital. Conclusion: An increased WBC count within the first 12 h of onset of an ischemic stroke is a strong prognostic factor for in-hospital mortality.

P556 The predictive value of white blood cell count and hematocrit measured at admission with in-hospital mortality in acute stroke patients

P556 The predictive value of white blood cell count and hematocrit measured at admission with in-hospital mortality in acute stroke patients

Swallowing, Nutrition, and Hydration During Acute Stroke Care

Dysphagia occurs in up to half of patients after an acute stroke and may cause dehydration, undernutrition, and aspiration pneumonia. Current evidence suggests that a systematic program of diagnosis and treatment of dysphagia in an acute stroke management plan may yield dramatic reductions in aspiration pneumonia rates. There is also some evidence that nutritional supplementation and proper hydration may reduce morbidity and mortality in acute stroke patients. This article focuses on the recent advances in the evaluation and management of dysphagia, undernutrition, and dehydration related to acute stroke. A summary of pertinent studies in the area of stroke dysphagia and nutrition is also included.

Re: Characteristics, Outcome, and Care of Stroke Associated With Atrial Fibrillation in Europe

To the Editor: I read with great interest the detailed study of atrial fibrillation1 in the context of acute stroke with particular relevance to the higher 3-month mortality of acute stroke patients who have atrial fibrillation (AF). We have previously reported2 the higher 3-month mortality of AF patients presenting with a stroke. It should be recognized, however, that AF is only one aspect of the cardiovascular disease (CVD) of these patients and does not usually exist independently of other types of CVD (eg, ischemic heart disease and cardiac failure) in the older age group. …

WHAT INFLUENCES OUTCOME OF STROKE – PYREXIA OR DYSPHAGIA?

SUMMARYTo investigate the significance of pyrexia and dysphagia as risk factors for mortality at 90 days in patients admitted with an acute stroke when controlled with other confounding factors, 202 stroke patients admitted to acute medical wards were prospectively studied for demographic and neurological details, stroke syndromes and pathology. A number of other factors were recorded within three days of admission, including pyrexia and dysphagia. Cox's proportional hazards model was used to identify the effect of 10 factors on mortality at 90 days; 59 (29%) patients had died by 90 days. Univariate analysis revealed pyrexia and dysphagia to be independently and significantly associated with indices of stroke severity and 90 day mortality (p&lt;0.001 for both). Cox's proportional hazards model, however, revealed that stroke mortality was associated with dysphagia (relative risk 2.6, 95% CI 1.2–5.4; p=0.009), pre‐existing diabetes mellitus (2.4, CI 1.2–4.5; p=0.006), higher age &gt;75 years (1.8, CI 1.0–3.1), ischaemic heart disease (2.1, CI 1.1–4.2, p=0.025), total anterior circulation syndromes (2.8, CI 1.5–5.2) and previous stroke (1.8, CI 1.0–3.2, p=0.028). Pyrexia was not a significant factor (p=0.50). Although both pyrexia and dysphagia are associated with higher mortality in acute stroke patients, dysphagia was a significant variable predicting death at 90 days when controlled for other factors known to influence stroke mortality. Pyrexia is not significant when other variables are considered.