Mortality In Ischemic Stroke Patients Research Articles

Mortality in patients treated by intra-venous thrombolysis for ischaemic stroke

In patients treated by intravenous (i.v.) thrombolysis, mortality rates range from 10 to 20 % at 3 months. The objective of this study was to determine the timing, causes and predictors of early (within 7 days) and delayed (8 days to 3 months) death after i.v. thrombolysis for cerebral ischaemia. We analyzed timing, causes and predictors of early and delayed mortality in a hospital-based registry of consecutive patients treated by i.v. thrombolysis for cerebral ischaemia. Of 500 patients (246 men; median age 71 years; median baseline National Institutes of Health Stroke Scale score 12; median onset-to-needle time 148 min), 76 (15.2%; 95% confidence interval [CI]: 12.3-18.6%) died within 3 months. Of 29 patients with early death, 21 (72.4%; 95% CI: 54.3-85.3%) died from neurovascular causes. Factors independently associated with early death were neurological complications and having had transient ischaemic attacks within the last 7 days. Of 47 patients with delayed death, 24 (51.1%; 95 % CI: 37.2-64.7%) died from infection, all but 1 having a modified Rankin scale >4 at 7 days. Factors independently associated with delayed death were pre-existing conditions and infections. Early and delayed mortality in ischaemic stroke patients are is highly dependent on the neurological status and response to thrombolysis. The target for reducing mortality is therefore to improve response to thrombolysis by any means, which can currently be achieved only by reducing delays.

Derivation and Validation of In-Hospital Mortality Prediction Models in Ischaemic Stroke Patients Using Administrative Data

Background: Stroke and other cerebrovascular diseases are a major cause of death and disability. Predicting in-hospital mortality in ischaemic stroke patients can help to identify high-risk patients and guide treatment approaches. Chart reviews provide important clinical information for mortality prediction, but are laborious and limiting in sample sizes. Administrative data allow for large-scale multi-institutional analyses but lack the necessary clinical information for outcome research. However, administrative claims data in Japan has seen the recent inclusion of patient consciousness and disability information, which may allow more accurate mortality prediction using administrative data alone. The aim of this study was to derive and validate models to predict in-hospital mortality in patients admitted for ischaemic stroke using administrative data. Methods: The sample consisted of 21,445 patients from 176 Japanese hospitals, who were randomly divided into derivation and validation subgroups. Multivariable logistic regression models were developed using 7- and 30-day and overall in-hospital mortality as dependent variables. Independent variables included patient age, sex, comorbidities upon admission, Japan Coma Scale (JCS) score, Barthel Index score, modified Rankin Scale (mRS) score, and admissions after hours and on weekends/public holidays. Models were developed in the derivation subgroup, and coefficients from these models were applied to the validation subgroup. Predictive ability was analysed using C-statistics; calibration was evaluated with Hosmer-Lemeshow χ² tests. Results: All three models showed predictive abilities similar or surpassing that of chart review-based models. The C-statistics were highest in the 7-day in-hospital mortality prediction model, at 0.906 and 0.901 in the derivation and validation subgroups, respectively. For the 30-day in-hospital mortality prediction models, the C-statistics for the derivation and validation subgroups were 0.893 and 0.872, respectively; in overall in-hospital mortality prediction these values were 0.883 and 0.876. Conclusions: In this study, we have derived and validated in-hospital mortality prediction models for three different time spans using a large population of ischaemic stroke patients in a multi-institutional analysis. The recent inclusion of JCS, Barthel Index, and mRS scores in Japanese administrative data has allowed the prediction of in-hospital mortality with accuracy comparable to that of chart review analyses. The models developed using administrative data had consistently high predictive abilities for all models in both the derivation and validation subgroups. These results have implications in the role of administrative data in future mortality prediction analyses.

Abstract 2510: Hemodialysis Is A Risk Factor For Short Or Long Term Mortality In Ischemic Stroke Patints.

Background and purpose Hemodialysis(HD) is reported to be a risk factor for cerebrovascular events and poor prognosis. However, it is unclear whether HD is a risk factor for short or long term mortality in ischemic stroke patients. The aim of the present study was to investigate whether a short or long term mortality of stroke patient s receiving HD is higher than those without HD. Methods From April 2007 to May 2010, we retrospectively enrolled ischemic stroke patients within 24h of stroke onset who admitted to our hospital. We divided patients into two groups according to presence and absence of receiving HD(HD group and non-HD group) . We compared clinical characteristics and the mortality rate at discharge and 1year after stroke onset between the two groups. The factors associated with death were investigated by multivariate logistic regression analysis. Results 687 patients (417 males; (61.4%), mean age 72.4 ± 11 years) were enrolled. 29 patients (4.0%) had HD. HD group was younger(69.8±14.2 vs. 73.0±11.9 year,P<0.001), and hypertension(97%vs. 68%, P<0.001) and basilar artery occlusion(10% vs. 2%, P=0.01) were more frequently observed than non-HD group . In-hospital mortality was 6.7% (46/687 patients). HD group was high mortality rate compared with non HD group(21%vs. 6%, P=0.002). Multivariate logistic regression analysis demonstrated that higher NIHSS score on admission, (OR 1.2, 95% CI 1.109-1.207, P <0.001), basilar artery occlusion (OR 3.6, 95% CI 1.031-12.36, P = 0.05), and HD(OR 7.8, 95%CI 2.259-26.79, P = 0.001) were independent factors associated with in-hospital death. Next, after hospital discharge, 14.5% of patients died within 1 year. HD group was high mortality rate compared with non HD group(50%vs. 13%, P<0.001). On multivariate regression analysis, age per 1year increase(OR 1.0, 95%CI 1.015-1.078, P = 0.03), poor functional outcome (modified Ranking Scale (3-5)) at discharge (OR 2.0, 95%CI 1.635-2.599, P <0.001), and HD(OR 26.4, 95%CI 7.532-92.503, P <0.001) were independent factors associated with death within 1year of stroke onset. Therefore, HD was independently associated with short or long term mortality. Conclusions; HD is a risk factor for short or long term mortality in ischemic stroke patients.

The Triple Rule-Out for Acute Ischemic Stroke: Imaging the Brain, Carotid Arteries, Aorta, and Heart

Ischemic stroke is commonly embolic, either from carotid atherosclerosis or from cardiac origin. These potential sources of emboli need to be investigated to accurately prescribe secondary stroke prevention. Moreover, the mortality in ischemic stroke patients due to ischemic heart disease is greater than that of age-matched controls, thus making evaluation for coronary artery disease important in this patient population. The purpose of this study was to evaluate the image quality of a comprehensive CTA protocol in patients with acute stroke that expands the standard CTA coverage to include all 4 chambers of the heart and the coronary arteries. One hundred twenty patients consecutively admitted to the emergency department with suspected cerebrovascular ischemia undergoing standard-of-care CTA were prospectively enrolled in our study. We used an original tailored acquisition protocol using a 64-section CT scanner, consisting of a dual-phase intravenous injection of iodinated contrast and saline flush, in conjunction with a dual-phase CT acquisition, ascending from the top of the aortic arch to the vertex of the head, then descending from the top of the aortic arch to the diaphragm. No beta blockers were administered. The image quality, attenuation, and CNRs of the carotid, aortic, vertebral, and coronary arteries were assessed. Carotid, aorta, and vertebral artery image quality was 100% diagnostic (rated good or excellent) in all patients. Coronary artery image quality was diagnostic in 58% of RCA segments, 73% of LAD segments, and 63% of LCX segments. When we considered proximal segments only, the diagnostic quality rose to 71% in the RCA, 83% in the LAD, and 74% in the LCX. Our stroke protocol achieved excellent opacification of the left heart chambers, the cervical arteries, and each coronary artery, in addition to adequate carotid and coronary artery image quality.

Serum Albumin in Ischemic Stroke Patients: The Higher the Better

Background: Animal studies show a neuroprotective effect of serum albumin in ischemic stroke. The neuroprotective effect of albumin in ischemic stroke in humans is not well studied. This study was aimed to determine the association of serum albumin with outcome and mortality after ischemic stroke. Methods: In a prospective study, we included 444 patients with ischemic stroke. Serum albumin was measured at the time of admission. Stroke severity was measured at the time of admission with the National Institutes of Health Stroke Scale (NIHSS). Functional outcome was measured with the modified Rankin scale (mRS) on day 7. Multiple logistic regression analysis was used to assess the independent association between variables and outcome. Survival was analyzed by Cox regression analysis after adjusting for age, sex and NIHSS score on admission. Results: The mean age (SD) of the patients was 70.4 (14.4) years. The median NIHSS score (interquartile range) on admission was 4 (1–8) and the median mRS score (interquartile range) on day 7 was 2 (1–3). Sixty patients (13%) died during a median follow-up period of 2 years. High serum albumin was independently associated with a better outcome (OR = 1.12, 95% CI = 1.05–1.20, p = 0.001). After adjusting for age, sex and NIHSS score on admission, high serum albumin was associated with lower mortality (OR = 0.88, 95% CI = 0.83–0.93, p < 0.0001). Conclusions: The current study indicates that high serum albumin is associated with better outcome and lower mortality in ischemic stroke patients. High serum albumin may be neuroprotective in ischemic stroke in humans.

Can Comprehensive Stroke Centers Erase the ‘Weekend Effect’?

Background: Prior epidemiological work has shown higher mortality in ischemic stroke patients admitted on weekends, which has been termed the ‘weekend effect’. Our aim was to assess stroke patient outcomes in order to determine the significance of the ‘weekend effect’ at 2 comprehensive stroke centers. Methods: Consecutive stroke patients were identified using prospective databases. Patients were categorized into 4 groups: intracerebral hemorrhage (ICH group), ischemic strokes not treated with IV t-PA (intravenous tissue plasminogen activator; IS group), acute ischemic strokes treated with IV t-PA (AIS-TPA group), and transient ischemic attack (TIA group). Weekend admission was defined as the period from Friday, 17:01, to Monday, 08:59. Patients treated beyond the 3-hour window, receiving intra-arterial therapy, or enrolled in nonobservational clinical trials were excluded. Patient demographics, NIHSS scores, and admission glucose levels were examined. Adverse events, poor functional outcome (modified Rankin scale, mRS, 3–6), and mortality were compared. Results: A total of 2,211 patients were included (1,407 site 1, 804 site 2). Thirty-six percent (800/2,211) arrived on a weekend. No significant differences were found in the ICH, IS, AIS-TPA, or TIA groups with respect to the rate of symptomatic ICH, mRS on discharge, discharge disposition, 90-day mRS, or 90-day mortality when comparing weekend and weekday groups. Using multivariate logistic regression to adjust for site, age, admission NIHSS, and blood glucose, weekend admission was not a significant independent predictive factor for in-hospital mortality in all strokes (OR = 1.10, 95% CI 0.74–1.63, p = 0.631). Conclusions: Our results suggest that comprehensive stroke centers (CSC) may ameliorate the ‘weekend effect’ in stroke patients. These results may be due to 24/7 availability of stroke specialists, advanced neuroimaging, or ongoing training and surveillance of specialized nursing care available at CSC. While encouraging, these results require confirmation in prospective studies.

Impact of Anticoagulation on Poststroke Mortality in Ischemic Stroke Patients With Atrial Fibrillation

To the Editor: We read with great interest the recent study by Andersen and Olsen regarding the usefulness of anticoagulation treatment in reducing poststroke mortality in patients with ischemic stroke (IS) and atrial fibrillation (AF). The authors, after evaluating data from a prospective nationwide registry, concluded that IS patients with AF and no contraindication to oral anticoagulants (OA) had an almost 50% reduction in the hazard of death when secondary prevention with anticoagulation treatment was instituted. This effect was independent of age, stroke severity, and stroke risk factors.1 The former findings raise certain potential clinical implications regarding the optimal …

Neurologic and Non-neurologic Predictors of Mortality in Ischemic Stroke Patients Admitted to the Intensive Care Unit

Patients with severe strokes may have different associated medical comorbidities from those with mild strokes. This study evaluated the neurologic and non-neurologic medical predictors of mortality in patients with severe cerebral infarction in the acute stage. Patients admitted to a neurologic intensive care unit (ICU) due to cerebral infarction were included. Neurologic and non-neurologic predictors for in-unit mortality were determined by logistic regression analyses. Two models using (A) neurologic factors and (B) combined neurologic and non-neurologic factors as mortality predictors were developed. The performance of the models in predicting overall, neurologic and non-neurologic mortalities was compared by areas under the receiver-operating characteristic curves (AUC) of the derived regressive equations. Of 231 patients with cerebral infarction admitted to the ICU, 34 (14.7%) died during ICU stay. Conscious state and acute physiologic abnormalities were significant predictors of mortality. The length of ICU stay in patients with non-neurologic mortality was longer than in those with neurologic mortality (p = 0.044). The AUC of Model B was larger than that of Model A in predicting overall (0.768 +/- 0.045 vs. 0.863 +/- 0.033, p = 0.005) and non-neurologic mortalities (0.570 +/- 0.073 vs. 0.707 +/- 0.074, p = 0.009), while there was no difference in predicting death from neurologic causes (0.858 +/- 0.044 vs. 0.880 +/- 0.032, p = 0.217). Impaired consciousness and acute physiologic abnormalities are independent predictors of mortality for severe ischemic stroke during the acute stage. Neurologic factors predict early mortality from intrinsic cerebral dysfunction, while non-neurologic factors, especially the associated physiologic abnormalities, predict late mortality from medical complications.

Predictors of Long-Term Mortality in Patients With Ischemic Stroke Referred for Transesophageal Echocardiography

Findings on transesophageal echocardiography (TEE) after ischemic stroke predict recurrent embolic events and prompt therapy; however, the additive predictive power of TEE findings on long-term mortality is unknown. Our goal was to study the impact of TEE findings on all cause mortality in ischemic stroke patients referred for TEE. We reviewed 245 consecutive patients who underwent TEE for ischemic stroke of undetermined origin (2000 to 2003). Long-term survival was assessed using the Social Security Death Index. In a mean follow-up period of 3.0 (1.4 to 4.8) years, death occurred in 19.2% of patients. TEE findings included patent foramen ovale (18.8%), left atrium/left ventricle thrombus (2.4%), spontaneous echo contrast (3.7%), atrial septal aneurysm (3.3%), valve vegetation/mass/tumor (7.8%), complex aortic atheroma ([CAA]; 14.7%), and the composite of any cardiac source of embolus (39.2%). A total atherosclerotic burden (TAB) score was also recorded. On Cox hazard regression analysis, measures of aortic atherosclerosis (CAA [hazard ratio (HR), 2.7; 95% CI, 1.4 to 5.3] or TAB score [HR, 1.4; 95% CI, 1.2 to 1.6]) were independent predictors of death, whereas other TEE findings were not. In patients with ischemic stroke of undetermined origin referred for TEE, measures of aortic atherosclerosis, including CAA, represent the only TEE findings that predict long-term mortality after all other clinical factors are considered. Further study is needed to determine whether treatments for CAA effect long-term survival in patients with ischemic stroke.

Frequency of Thrombolytic Therapy in Patients With Acute Ischemic Stroke and the Risk of In-Hospital Mortality

There is little information about early outcome after intravenous application of tissue-type plasminogen activator (tPA) for stroke patients treated in community-based settings. We investigated the association between tPA therapy and in-hospital mortality in a pooled analysis of German stroke registers. Ischemic stroke patients admitted to hospitals cooperating within the German Stroke Registers Study Group (ADSR) between January 1, 2000, and December 31, 2000, were analyzed. The ADSR is a network of regional stroke registers, combining data from 104 academic and community hospitals throughout Germany. Patients treated with tPA were matched to patients not receiving tPA on the basis of propensity scores and were analyzed with conditional logistic regression. Analyses were stratified for hospital experience with the administration of tPA. A total of 13,440 ischemic stroke patients were included. Of these, 384 patients (3%) were treated with tPA. In-hospital mortality was significantly higher for patients treated with tPA compared with patients not receiving tPA (11.7% versus 4.5%, respectively; P<0.0001). After matching for propensity score, overall risk of inpatient death was still increased for patients treated with tPA (odds ratio [OR], 1.7; 95% CI, 1.0 to 2.8). Patients receiving tPA in hospitals that administered <or=5 thrombolytic therapies in 2000 had an increased risk of in-hospital mortality (OR, 3.3; 95% CI, 1.1 to 9.9). No significant influence of tPA use for risk of inpatient death was found in hospitals administering >5 thrombolytic treatments per year (OR, 1.3; 95% CI, 0.8 to 2.4). In-hospital mortality of ischemic stroke patients after tPA use varied between hospitals with different experience in tPA treatment in routine clinical practice. Our study suggested that thrombolytic therapy in hospitals with limited experience in its application increase the risk of in-hospital mortality.