Non-stroke Group Research Articles

Clinical nutrition and gastrointestinal dysfunction in critically ill stroke patients

Background Data on the epidemiology and risk factors of altered gastrointestinal motility (AGIM) is virtually lacking for patients suffering from non-traumatic neurologic diseases and stroke. This study investigated whether patterns of AGIM differ between patients with stroke and other severe acute brain diseases. Methods Clinical records of stroke and non-stroke patients treated at a neurological intensive care unit (ICU) were reviewed at day 1–5 and at day 10 after admission. The data was analyzed for the course of enteral/parenteral nutrition and for and for signs and symptoms of gastrointestinal dysfunction. The study included data of 76 patients, 57 with stroke (stroke group, SG) and 19 with other neurological diseases (non-stroke group, NSG). Results Basic demographic as well as clinical baseline characteristics and alimentation regime were similar in both groups. At least one sign of AGIM was seen in 33/57 (58%) SG and in 15/19 (79%) NSG patients (P = 0.099). Regurgitation was significantly more frequent among patients from the NSG (P < 0.05). Subjects from the NSG also spent a higher proportion of time with at least one symptom of AGIM present (P < 0.05). Conclusions For the first time, this study investigated the prevalence of AGIM in patients suffering from severe stroke. The prevalence of disturbed gastrointestinal function was found to be high in stroke patients, but was lower than in a group of non-stroke patients with similar general disease severity and baseline characteristics.

Transurethral resection of the prostate achieves favorable outcomes in stroke patients with symptomatic benign prostate hyperplasia

Objectives: To evaluate the surgical outcomes of stroke patients with symptomatic benign prostatic hyperplasia (BPH) who underwent transurethral resection of the prostate (TURP) and compare the clinical outcomes between patients with stroke and those without stroke receiving this procedure.Methods: This retrospective cohort study analyzed claims data collected during the period of 1997–2012 from Taiwan National Health Insurance Research Database. We enrolled 6625 patients who had persistent lower urinary tract symptoms and underwent TURP for BPH. They were categorized into a stroke (n = 577) and nonstroke (n = 6048) group. Patient characteristics, postoperative clinical outcomes, medication records, and medical expenses were compared.Results: Compared with the stroke group patients, those in the nonstroke group were younger, had fewer comorbidities, and more favorable postoperative clinical outcomes. Nevertheless, TURP achieved favorable outcomes in stroke patients with symptomatic BPH. In the stroke group, the rate of urinary tract infection (UTI) decreased from 34.7% during 1 year preoperatively to 29.8% during 1 year postoperatively (p = .05). The rate of urinary retention (UR) also decreased from 55.5% during 1 year preoperatively to 22.5% during 1 year postoperatively (p = .05). TURP reduced the overall medical expenses of patients with stroke. Annual patient medical expense during 1 year preoperatively, 1 year postoperatively, 2 years postoperatively, and 3 years postoperatively was NT$659,000, NT$646,000, NT$560,000, and NT$599,000, respectively.Conclusions: In patients with stroke, TURP reduces the risks of UTI and UR and annual total medical expense.

Risk of developing pleural empyema in patients with stroke: a propensity-matched cohort study.

Pleural empyema is an important complication of pneumonia. Patients with stroke are at a higher risk developing pneumonia; however, the association between stroke and pleural empyema risk is largely unknown. We used the data from the National Health Insurance Research Database of Taiwan to establish a stroke group consisting of 466,170 patients diagnosed between 2000 and 2010, and a non-stroke group consisting of the same number of individuals matched by the propensity score. Incident pleural empyema was monitored toward the end of 2011. Adjusted hazard ratios (aHRs) of pleural empyema in the stroke group, compared to the non-stroke group, were estimated using the Cox proportional hazards model. We found that the incidence of pleural empyema is 2.69-fold higher in the stroke group than in the non-stroke group (15.2 vs. 5.59/10,000 person-years, p<0.001), with an aHR of 2.89 [95% confidence interval (CI)=2.72-3.08]. Further analysis reveals the aHRs of pleural empyema to be 2.62 (95% CI=2.45-2.79) in patients with ischemic stroke and 4.53 (95% CI=4.14-4.95) in patients with hemorrhagic stroke compared with those without stroke. In addition, we observe that stroke patients with ventriculoperitoneal (VP) shunt implantation exhibit more than sevenfold risk for developing of pleural empyema. In conclusion, patients with stroke are at an elevated risk of developing pleural empyema. The risk is greater for those with hemorrhagic stroke than for those with ischemic stroke. The risk increases further for patients who undergo VP shunt implantation.

Dementia and Death After Stroke in Older Adults During a 10-year Follow-up: Results from a Competing Risk Model.

To investigate the association between stroke and incident dementia in the presence of a competing risk of death. This study used the National Health Insurance Service-Senior (NHIS-Senior) claim database from 2002 to 2013 (n = 22,792). Stroke (I69.0-I69.9) and dementia (F01-F03, G30, G31.1) patients were defined by the International Classification of Disease 10th revision. The association of stroke with dementia or death was assessed with Cox proportional hazards model and competing-risk model. During the 10-year follow-up period, there were 1,307 dementia events (5.7%) and 9,272 deaths (40.7%). In the Cox model, the adjusted hazard ratio (HR) for dementia was 2.37 times higher in those who experienced strokes, compared with the non-stroke group (95% CI: 2.23, 2.51). In the presence of death as competing event, stroke was associated with an elevated dementia incidence (HR = 2.06, 95% CI: 1.92, 2.20). Stroke was significantly associated with an increased risk of incident dementia, with the magnitude of the association being attenuated in the competing risk model.

Abstract 84: Ischemic and Hemorrhagic Stroke in Infective Endocarditis: Features, Predictors and Trends Over Three Decades

Background: Stroke is a major complication of infective endocarditis (IE). The features and predictors of ischemic and hemorrhagic stroke subtypes are unknown. Methods and Results: In this retrospective study (1980-2011) we used original Duke criteria to diagnose IE in 1149 episodes (1081 patients; 81% definite, 80% native valve). Neuro complications occurred in 28% including infarcts (17.6%), ICH (4.6%), meningitis (4%), brain/spinal abscess (8%), and seizures (2%). Ischemic stroke was the isolated presenting symptom in 11%; its most frequent presentations were total/partial anterior-circulation syndrome (47%) and embolic encephalopathy (21%). On DWI, infarcts were disseminated small (45%) or multi-sized (31%), single (16%), or territorial (9%). Disseminated infarcts were associated with poor outcome (p=0.026). Post-ischemic hemorrhage occurred in 6.4%. Primary ICH was evident on admission in 55% including 36 parenchymal (92% lobar), 13 SAH (69% convexal) and 4 SDH. As compared to the non-stroke group (n=885), the ischemic (n=202) and hemorrhagic stroke (n=53) groups had higher rates of complications (e.g., meningitis, seizures, sepsis, renal failure), longer LOS, higher mortality, and lower rates of home discharge (all p&lt;0.05). Both stroke groups had higher rates of S. viridans and Group B strep infections and more valvular vegetations; the ischemic stroke group had more intracardiac thrombi, and the hemorrhagic stroke group had more mechanical valve infection (all p&lt;0.05). Heparin use was associated with a higher rate of new infarcts (12% vs. 5%, p=0.027) but not ICH (2.4% vs. 1.4%, p=0.6). Overall mortality (14.6%) was higher in both stroke groups, however both groups had similar neurological mortality. Mitral valve involvement, sepsis, and strep infections were independent predictors of both ischemic and hemorrhagic stroke. Age, renal failure, heart failure, sepsis, and Staph aureus endocarditis were independent predictors of non-home discharge. Over three decades the LOS decreased, ischemic stroke rates increased, but there was no change in ICH or mortality rates. Conclusion: Endocarditis-related ischemic and hemorrhagic stroke subtypes have overlapping risk factors, predictors, clinical phenotypes, and effects on outcome.

The Factors Associated With Health-Related Quality of Life in Stroke Survivors Age 40 and Older.

ObjectiveTo evaluate the association between clinical and socio-demographic status and health-related quality of life (HR-QoL) in stroke survivors age 40 and older in the Korean population.MethodsThe relationship between stroke and HR-QoL was investigated using data from the Korea National Health and Nutrition Examination Survey (KNHANES), conducted from 2007–2012. The total number of respondents was 24,050 and 757 stroke survivors were included. Specifically, we investigated factors associated with the lowering of HR-QoL in a group of Korean adult stroke patients age 40 and older after adjusting for socio-demographic factors, anthropometric measurements, and clinical comorbidities. Adjusted effects of covariates on EuroQol-visual analog scales (EQ-VAS) scores were estimated with a complex-samples general linear model and multivariate-adjusted odds ratios of the lowest quintile versus highest quintile of the EQ-VAS scores in the stroke group were estimated with a complex-samples logistic regression model.ResultsSocio-demographic, anthropometric factors, and clinical comorbidities significantly differed between the stroke and non-stroke groups, except regarding gender and residential area. The EQ-VAS was significantly lower in the stroke than non-stroke group. Anxiety/depression problems significantly lowered EQ-VAS, as did low education level, smoking, mobility and usual activities problems. Also, aging in 1-year increments and cardiovascular disease had a significant effect on lower EQ-VAS in stroke survivors.ConclusionPeople with a stroke have significantly lower HR-QoL than healthy subjects. Therefore, managing depression, smoking, or cardiovascular disease and maintenance of physical function may be priority goals in improving HR-QoL after a stroke.

The prevalence of stroke and depression and factors associated with depression in elderly people with and without stroke.

BackgroundFew studies have investigated factors associated with depression among elderly people with and without stroke concurrently, using identical settings, procedures and study variables. The aim was to investigate the prevalence of stroke and depression and to compare the factors associated with depression in people with and without stroke.MethodsA postal mail survey was sent to 65-, 70-, 75- and 80-year-olds in northern Sweden and Finland in 2010 (n = 6098). Stroke was defined as answering “yes” to the question “Have you had a stroke?” Depression was defined as answering “yes” to the question “Are you depressed?” or having a Geriatric Depression Scale-4 score ≥2. Dependence in personal activities of daily living was defined as not showering without human assistance. Associations were tested with log-binomial regression.ResultsThe overall stroke prevalence was 7.0 ± 0.3 % and increased from 4.7 ± 0.4 % among 65-year-olds to 11.6 ± 1.0 % among 80-year-olds (p < 0.001). The overall depression prevalence was 12.8 ± 0.4 % and increased from 11.0 ± 0.6 % among 65-year-olds to 18.1 ± 1.2 % among 80-year-olds (p < 0.001). Depression was more common among people with stroke (Prevalence Ratio 1.77, 95 % Confidence Interval 1.48-2.12).In the non-stroke group, depression was independently associated with diabetes, dependence in instrumental activities of daily living, living alone, not having someone to talk to, poor finances, pain problems and having a life crisis in the preceding year. In the group with stroke, depression was independently associated with dependence in personal activities of daily living and having a life crisis the preceding year.ConclusionsDepression in people without stroke appeared to be independently associated with a broader range of external factors than depression in people with stroke.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-016-0347-6) contains supplementary material, which is available to authorized users.

Anatomical Directional Dissimilarities in Tri-axial Swallowing Accelerometry Signals.

Swallowing accelerometry is a noninvasive approach currently under consideration as an instrumental screening test for swallowing difficulties, with most current studies focusing on the swallowing vibrations in the anterior-posterior (A-P) and superior-inferior (S-I) directions. However, the displacement of the hyolaryngeal structure during the act of swallowing in patients with dysphagia involves declination of the medial-lateral (M-L), which suggests that the swallowing vibrations in the M-L direction have the ability to reveal additional details about the swallowing function. With this motivation, we performed a broad comparison of the swallowing vibrations in all three anatomical directions. Tri-axial swallowing accelerometry signals were concurrently collected from 72 dysphagic patients undergoing videofluoroscopic evaluation of swallowing (mean age: 63.94 ± 12.58 years period). Participants swallowed one or more thickened liquids with different consistencies including thin-thick liquids, nectar-thick liquids, and pudding-thick liquids with either a comfortable self-selected volume from a cup or a controlled volume by the examiner from a 5-ml spoon. Swallows were grouped based on the viscosity of swallows and the participant's stroke history. Then, a comprehensive set of features was extracted in multiple signal domains from 881 swallows. The results highlighted inter-axis dissimilarities among tri-axial swallowing vibrations including the extent of variability in the amplitude of signals, the degree of predictability of signals, and the extent of disordered behavior of signals in time-frequency domain. First, the upward movement of the hyolaryngeal structure, representing the S-I signals, were actually more variable in amplitude and showed less predictable behavior than the sideways and forward movements, representing the A-P and M-L signals, during swallowing. Second, the S-I signals, which represent the upward movement of the hyolaryngeal structure, behaved more disordered in the time-frequency domain than the sideways movement, M-L signals, in all groups of study except for the pudding swallows in the stroke group. Third, considering the viscosity and the participant's pathology, thin liquid swallows in the nonstroke group presented the most directional differences among all groups of study. In summary, despite some directional dissimilarities, M-L axis accelerometry characteristics are similar to those of the two other axes. This indicates that M-L axis characteristics, which cannot be observed in videofluoroscopic images, can be adequately derived from the A-P and S-I axes.

Falls and Fear of Falling After Stroke: A Case-Control Study

BackgroundFalls are common after stroke, with potentially serious consequences. Few investigations have included age-matched control participants to directly compare fall characteristics between older adults with and without stroke. Further, fear of falling, a significant psychological consequence of falls, has only been examined to a limited degree as a risk factor for future falls in a stroke population. ObjectiveTo compare the fall history between older adults with and without a previous stroke and to identify the determinants of falls and fear of falling in older stroke survivors. DesignCase-control observational study. SettingPrimary teaching hospital. ParticipantsSeventy-five patients with stroke (mean age ± standard deviation, 66 ± 7 years) and 50 age-matched control participants with no previous stroke were tested. MethodsFall history, fear of falling, and physical, cognitive, and psychological function were assessed. A χ2 test was performed to compare characteristics between groups, and logistic regression was performed to determine the risk factors for falls and fear of falling. Main Outcome MeasuresFall events in the past 12 months, Fall Efficacy Scale–International, Berg Balance Scale, Functional Ambulation Category, Fatigue Severity Scale, Montreal Cognitive Assessment, and Patient Healthy Questionnaire–9 were measured for all participants. Fugl-Meyer Motor Assessment was used to quantify severity of stroke motor impairments. ResultsTwenty-three patients and 13 control participants reported at least one fall in the past 12 months (P = .58). Nine participants with stroke had recurrent falls (≥2 falls) compared with none of the control participants (P < .01). Participants with stroke reported greater concern for falling than did nonstroke control participants (P < .01). Female gender was associated with falls in the nonstroke group, whereas falls in the stroke group were not significantly associated with any measured outcomes. Fear of falling in the stroke group was associated with functional ambulation level and balance. Functional ambulation level alone explained 22% of variance in fear of falling in the stroke group. ConclusionsCompared with persons without a stroke, patients with stroke were significantly more likely to experience recurrent falls and fear of falling. Falls in patients with stroke were not explained by any of the outcome measures used, whereas fear of falling was predicted by functional ambulation level. This study has identified potentially modifiable risk factors with which to devise future prevention strategies for falls in patients with stroke. Level of EvidenceIII

The value of calcaneal quantitative ultrasound(QUS) T score under -2.5 in predicting stroke

Objective To explore the relationship between risk of stroke and calcaneal quantitative ultrasound(QUS)T score under -2.5. Methods 5 847 subjects over the age of 40 from Yunyan District, Guiyang City were investigated with questionnaire, physical examination, blood lipids, other metabolic indexes and calcaneus bone density determination from May to October, 2011 by cluster sampling method and were followed up for 3 years. Subjects were divided into stroke group(99 subjects)and non-stroke group(5 748 subjects) according to the occurrence of stroke in the follow-up period. The relationship between risk of stroke and QUS T score under -2.5 was analyzed. Results Compared to the non-stroke group, the number of subjects with T score under -2.5 in calcaneal QUS was larger in the stroke group, the difference of which was statistically significant(P<0.05). T score of bone density under -2.5 in calcaneal QUS was found to be an independent risk factor for predicting stroke after adjusting for age, sex, and body mass index(HR=1.467, 95%CI 0.753-2.855). The relationship between risk of stroke and T score under -2.5 in calcaneal QUS remained unchanged after further adjust ment of smoking, diabetes, education, and hypertension(HR=1.265, 95%CI 0.647-2.475). Conclusion The risk of stroke and T score of bone density under -2.5 in calcaneal QUS was independently associated, and the latter is an independent risk factor for predicting stroke. (Chin J Endocrinol Metab, 2016, 32: 395-398) Key words: Stroke; Ultrasonography; Calcaneus; Bone mineral density

Patient Survival and Technique Failure in Continuous Ambulatory Peritoneal Dialysis Patients with Prior Stroke.

♦ To investigate patient survival and technical failure of patients with prior stroke receiving continuous ambulatory peritoneal dialysis (CAPD) in Southern China. ♦ This was a retrospective study. All subjects were recruited from the peritoneal dialysis center in The First Affiliated Hospital of Sun Yat-sen University from 1 January 2006 to 31 December 2010. All eligible patients were assigned to stroke group and non-stroke group according to a history of stroke before receiving CAPD. The primary outcomes were all-cause mortality and death-censored technical failure. Cox regression was used to estimate risk factors of all-cause mortality and death-censored technique failure. ♦ Of the 1,068 recruited patients, 75 (7.0%) patients had a previous history of stroke. The all-cause mortality and death-censored technique failure were significantly higher in the stroke group compared with the non-stroke group, respectively (odds ratio [OR] 2.67, 95% confidence interval [CI] 1.59 - 4.46 and OR 2.52, 95% CI 1.19 - 5.34). Older age (changed by 10 years, hazard ratio [HR] 1.90, 95% CI 1.07 - 3.38), lower body mass index (BMI 18.5 - 23.9 vs < 18.5 kg/m(2) reference, HR 0.17, 95% CI 0.05 - 0.55) and time to the first episode of peritonitis (HR 0.93, 95% CI 0.89 - 0.96) were independently associated with increased risk of all-cause mortality in patients with prior stroke. In addition, time to the first episode of peritonitis was associated with decreased risk of death-censored technique failure (HR 0.91, 95% CI 0.84 - 0.99) in those with prior stroke. ♦ Continuous ambulatory peritoneal dialysis patients with prior stroke had high rates of all-cause mortality and technique failure compared with those without prior stroke. Older age, lower BMI, and time to the first episode of peritonitis were independent risk factors of all-cause mortality in patients with prior stroke.

Apolipoprotein A1-Unique Peptide as a Diagnostic Biomarker for Acute Ischemic Stroke.

Clinically-informative biomarkers of ischemic stroke are needed for rapid diagnosis and timely treatment. In the present study, APOA1 unique peptide (APOA1-UP), a novel peptide biomarker, was identified and quantified by multiple reaction monitoring (MRM) using labeled reference peptide (LRP). Serum samples of 94 patients in the ischemic stroke group and 37 patients in the non-stroke group were analyzed for the levels of total APOA1-UP, low density lipoprotein cholesterol (LDL-C), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and total cholesterol (TC). Median ratio of total APOA1-UP/LRP was 2.14 (interquartile range, 0.40) in the non-stroke group and 1.32 (0.44) in the ischemic stroke group (p < 0.0001). The serum level of total APOA1-UP was independently correlated with the presence of ischemic stroke by multivariate logistic regression analysis (p < 0.0001). From the receiver operating characteristic (ROC) curve, the area under the curve (AUC) was 0.9750 and the optimal cutoff value of the serum APOA1-UP level was 1.80, which yielded a sensitivity of 90.63% and a specificity of 97.14%. The diagnostic efficiency of HDL-C was lower, with an AUC of 0.7488. Therefore, the serum level of APOA1-UP is a diagnostic biomarker candidate for ischemic stroke in the early stage.

Short Leukocyte Telomere Length Is Associated With Cardioembolic Stroke Risk in Patients With Atrial Fibrillation

The risk of cardioembolic stroke in patients with atrial fibrillation (AF) cannot be accurately assessed and novel tools are needed to improve prediction. We hypothesize that telomere shortening constitutes a novel risk factor for cardioembolic stroke in patients with AF. The peripheral blood leukocyte telomere length (LTL) was determined by real-time polymerase chain reaction in 187 patients with AF, 93 of them without stroke history and 94 of them having suffered 1 cardioembolic stroke. Percentiles were calculated according to LTL values in the nonstroke group to estimate the cardioembolic stroke risk associated with LTL using logistic regression models. Short LTL values were independently and dose-dependently associated with an increased risk of cardioembolic stroke, with an odds ratio (95% confidence interval) of 2.93 (1.24-6.94) and 6.26 (2.01-19.52), respectively, for sex, hypertension, diabetes mellitus, heart failure, and age-adjusted models using the LTL 10th and 5th percentile cut-offs, respectively. Telomere shortening is associated with cardioembolic stroke risk in patients with AF. Prospective studies are encouraged to establish the value of LTL to improve prediction tools to categorize cardioembolic stroke risk in AF.

Clinical usefulness of ankle brachial index and brachial-ankle pulse wave velocity in patients with ischemic stroke.

Ankle brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are widely used noninvasive modalities to evaluate atherosclerosis. Recently, evidence has increased supporting the use of ABI and baPWV as markers of cerebrovascular disease. This study sought to examine the relationship between ABI and baPWV with ischemic stroke. This study also aimed to determine which pathogenic mechanism, large artery disease (LAD) or small vessel disease (SVD), is related to ABI or baPWV. Retrospectively, 121 patients with ischemic stroke and 38 subjects with no obvious ischemic stroke history were recruited. First, ABI and baPWV were compared between the groups. Then, within the stroke group, the relevance of ABI and baPWV with regard to SVD and LAD, which were classified by brain magnetic resonance image (MRI) and magnetic resonance angiography (MRA) or computed tomography angiography (CTA) findings, was assessed. The baPWV was higher in the stroke group than non-stroke group (1,944.18±416.6 cm/s vs. 1,749.76±669.6 cm/s, P<0.01). Regarding LAD, we found that mean ABI value was lower in the group with extracranial large artery stenosis (P<0.01), and there was an inverse linear correlation between ABI and the grade of extracranial large artery stenosis (P<0.01). For SVD, there was a significant correlation between SVD and baPWV (2,057.6±456.57 cm/s in the SVD (+) group vs. 1,491±271.62 cm/s in the SVD (-) group; P<0.01). However, the grade of abnormalities detected in SVD did not correlate linearly with baPWV. These findings show that baPWV is a reliable surrogate marker of ischemic stroke. Furthermore, baPWV and ABI can be used to indicate the presence of small vessel disease and large arterial disease, respectively.

Abstract 17535: Carotid Artery Calcifications and High-risk Carotid Plaques Identified by CT Angiograms are Associated With an Increased Predisposition of Ischemic Strokes

Introduction: Ischemic strokes account for nearly 90% of all strokes in the United States. Non-invasive computed tomographic angiograms (CTA) are performed routinely in patients with stroke-like symptoms. While the severity of carotid stenosis is conventionally used to plan medical therapy or interventions, there is no data to predict the future risk of ischemic strokes based on additional high-risk characteristics that can be visualized by modern CTA. Methods: We examined the head and neck CTA of 485 patients who presented to our tertiary stroke center with symptoms suggestive of transient ischemic attacks or stroke. Using the post-processed CT images, we analyzed the severity of stenosis and plaque characteristics of the common, internal and external carotid arteries, and also evaluated for evidence of ischemic strokes. Carotid lesions were defined in terms of the degree of stenosis, calcifications (speckled or eccentric), presence of non-calcified plaques, positive remodeling, and presence of a Napkin-Ring Sign. Results: Of the 485 patients, 278 were males (mean age: 67 years), with 109 having a history of stroke. Our data showed that patients with unilateral or bilateral high-risk soft plaques and carotid calcifications visualized by CTA were associated with increased risk of ischemic cerebral events (p&lt;0.001). Additionally, we found that patients with stroke had a greater number of calcium speckles (6-speckles in stroke group vs 4-speckles in non-stroke group; P&lt;0.01) in their carotid arteries. Receiver-Operating Curve analysis showed that the presence of more than 2 speckles in the carotid arteries portends a higher likelihood of developing a stroke (P&lt;0.01). Conclusions: This novel study shows that the presence of carotid artery calcifications or non-calcified high-risk soft plaques on one or both carotid arteries, in addition to &gt;2 calcium speckles in the carotid arteries were associated with an ischemic stroke. These results emphasize that the nature of atherosclerosis, and utility of comprehensive non-invasive CTA to identify patients who are at higher risk of developing ischemic stroke with a goal of early therapeutic strategies.

High levels of von Willebrand factor and low levels of its cleaving protease, ADAMTS13, are associated with stroke in young HIV-infected patients.

Stroke associated with human immunodeficiency virus infection may occur through a variety of mechanisms. Von Willebrand factor is a marker of endothelial dysfunction, and is elevated in human immunodeficiency virus infection. High levels of von Willebrand factor, a protein involved in platelet adhesion and aggregation, and low levels of ADAMTS13, a metalloproteinase that cleaves von Willebrand factor, have been associated with an increased risk of thrombosis. To investigate the role of von Willebrand factor and ADAMTS13 in the pathogenesis of human immunodeficiency virus-related stroke in young patients. A case-control study (n = 100) comprising three participant groups: human immunodeficiency virus-positive antiretroviral therapy-naïve young strokes (n = 20), human immunodeficiency virus-negative young strokes (n = 40), and human immunodeficiency virus-positive antiretroviral therapy-naïve nonstroke controls (n = 40). von Willebrand factor and ADAMTS13 levels were measured in plasma samples collected five- to seven-days poststroke. Human immunodeficiency virus-positive stroke participants had higher von Willebrand factor levels than human immunodeficiency virus-negative strokes (173·5% vs. 135%, P = 0·032). They tended to have higher levels of von Willebrand factor than human immunodeficiency virus-positive nonstroke controls (173·5% vs. 129%, P = 0·061). Human immunodeficiency virus-positive stroke participants had lower levels of ADAMTS13 than human immunodeficiency virus-positive nonstroke controls (0% vs. 23·5% P = 0·018) most likely due to the effect of the acute stroke. However, in the nonstroke group, these levels were significantly reduced compared with population norms. von Willebrand factor levels in all human immunodeficiency virus-positive participants were negatively correlated with CD4 counts. Stroke in human immunodeficiency virus infection is associated with a prothrombotic state, characterized by elevated von Willebrand factor and low ADAMTS13 levels.

Impact of Surgical Stroke on the Early and Late Outcomes After Thoracic Aortic Operations

Thoracic aortic operations still remain associated with substantial risks of death and neurologic injury. This study investigated the impact of surgical stroke on the early and late outcomes, focusing on the physical status and quality of life (QOL). From 1986 to 2008, 500 patients (aged 63 ± 13 years) underwent open thoracic aortic repair for root and ascending (31%), arch (39%), extended arch (10%), and descending and thoracoabdominal (19%) aneurysms. Brain protection consisted of retrograde cerebral perfusion (52%), antegrade cerebral perfusion (29%), and simple deep hypothermic circulatory arrest (19%). Surgical stroke was defined as a neurologic deficit persisting more than 72 hours after the operation. QOL was assessed with the Short-Form 36 Health Survey Questionnaire 5.9 ± 4.2 years after the operation. Stroke occurred in 10.3% of patients. Hospital mortality was 21% in the stroke group and 2.7% in the nonstroke group (p < 0.001). At hospital discharge, 76% of survivors in the stroke group had permanent neurologic deficits (PNDs), with sustained tracheostomy in 39%, tube feeding in 46%, and gastrostomy in 14%, and 89% required transfer to other facilities. PND was an independent risk factor for late death (hazard ratio, 2.29; 95% confidence interval, 1.04 to 4.62; p= 0.041) in a multivariate analysis. The physical component of the QOL score was worse in the PND group (51% vs 100%; p= 0.039), whereas the mental component was similar in both groups (14% vs 14%). Surgical stroke is associated with high hospital mortality and PNDs that decrease late survival and the physical component score of the QOL survey.

Clinical significance of cerebral microbleeds locations in CADASIL with R544C NOTCH3 mutation.

Background and PurposeAlthough cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common single-gene disorder of cerebral small blood vessels caused by NOTCH3 mutations, little has been described about the variation in the clinical findings between its underlying types of mutations. In particular, the presence of cerebral microbleeds (CMBs) has been an increasingly recognized magnetic resonance imaging finding in CADASIL, but their clinical significance is not clear. The purpose of this study is to assess whether CMBs are associated with symptomatic stroke in the CADASIL patients with R544C mutation and to compare the cerebral distribution of CMBs between CADASIL patients with and without symptomatic stroke.MethodsThis is a cohort study of patients who were diagnosed with genotype-confirmed R544C-mutation CADASIL. Primary neurologic symptoms were recorded. Symptomatic strokes were defined as transient ischemic attack, ischemic strokes and hemorrhagic strokes. CMBs were defined as focal areas of round signal loss on T2*-weighted gradient echo planar images with a diameter of less than 10 mm. The locations of CMBs were divided into lobar, basal ganglia, thalamus, brain stem and cerebellum. Multiple logistic regressions were performed to identify the epidemiologic or vascular risk factors associated with symptomatic stroke in patients with CADASIL.ResultsAmong total of 51 subjects in this cohort, CMBs were present in 20 of 32 patients (64.5%) in the symptomatic stroke-group and in 8 of 19 patients (42.1%) in the non-stroke group (p = 0.16). CMBs were observed more frequently in the basal ganglia (p<0.001) and the cerebellum (p<0.018) in the symptomatic stoke group compared to the non-stroke group. The mean number of CMBs was significantly higher in the symptomatic stroke group (15.4±18.0 lesions per patients with CMBs) versus those without symptomatic stroke (3.3±3.0 lesions per patients with CMBs) (p = 0.003). Hypertension was an independent risk factor for symptomatic stroke in CADASIL (p = 0.014). It was independently associated with CMBs locations as basal ganglia (p = 0.016), thalamus (p = 0.010), brainstem (p = 0.044), and cerebellum (p = 0.049). However, It was not independently associated with CMBs on lobar lesion (p = 0.152).ConclusionsIn this study hypertension was an independent predictor of CMBs presence in specific brain locations, as well as symptomatic stroke in the CADASIL patients. The distribution and burden of CMBs might be a clinically useful marker for the risk of symptomatic stroke. However, further prospective studies on the relationship between CMBs distribution and symptomatic stroke are required in order to support these preliminary findings.

Abstract W P156: Arterial Stiffness in Older Adults With and Without Stroke

Introduction: Silent cerebrovascular infarcts resulting from vascular disease can manifest as a decline in cognitive function. These silent events are also associated with increased risk of clinically overt stroke. Arterial stiffness is a marker that represents atherosclerotic progression and is a predictor of cardiovascular events and mortality. This study examined the relationship between arterial stiffness and cognitive impairment between adults aged 50-80 years old with and without stroke. Hypothesis: We hypothesized that elevated arterial stiffness would be observed in individuals with stroke, and also be associated with increased cognitive impairment across all participants. Methods: Cognition was assessed using the Montreal Cognitive Assessment (MoCA). Arterial stiffness was quantified using carotid-femoral pulse wave velocity (cfPWV, in m/s), calculated as cfPWV=D/Δt, where D was the distance measured between arterial sites and Δt was the pulse transit time. Higher values represent increased stiffness, and values &gt;10 m/s are associated with increased risk for cardiovascular events. Results: Twenty-five participants were assessed: 11 participants 4.7±2.4 years post-stroke and 14 older adults without stroke. The non-stroke group was older (73.1±3.9 vs. 65.2±9.4 years, P=0.009), while the stroke group had lower MoCA scores (21.2±3.2 vs. 24.4±2.8, P=0.01). There were no between-group differences in cfPWV (stroke 9.4 m/s vs. older adults 9.9 m/s, P=0.49), when controlling for age and MoCA scores. In backward regression analysis, age explained 21% of the variance of cfPWV (P=0.03), while MoCA was not a contributor. Conclusions: In conclusion, these results suggest that age is a significant correlate of arterial stiffness, regardless of the presence of stroke or cognitive impairment. Ongoing work will examine whether stroke history also contributes to arterial stiffness when groups are matched for age.

Prior ischemic stroke is not associated with worse clinical outcomes in patients undergoing percutaneous coronary intervention.

Cerebrovascular accidents (CVAs) frequently coexist with coronary artery disease (CAD) and adversely affect prognosis in patients with CAD; however, fewer studies have investigated the role of prior ischemic stroke on the outcomes of percutaneous coronary intervention (PCI). The aim of this study was to determine the safety and effectiveness of PCI in patients with a prior ischemic stroke. A review of patients who underwent PCI between June 2003 and September 2005 (n=3893) at the Beijing Anzhen Hospital of Capital University of Medical Science, identified 295 PCI patients with a prior ischemic stroke (≥ 3 months) and 3598 patients without a prior stroke. To investigate whether prior history of an ischemic stroke was independently associated with increased risk of adverse PCI outcomes, prognostic parameters were analyzed using univariate analysis and Cox multivariate regression analysis. Propensity score analysis was then used to match the two subgroups of patients based on multiple factors known to impact cardiac outcome. Patients with a prior ischemic stroke had more frequent high-risk baseline characteristics (diabetes, hypertension, hyperlipidemia and prior myocardial infarction). No significant differences were found in the major adverse cardiac and cerebrovascular event (MACCEs) rates between the two groups (1.7% in the stroke group vs. 1.4% in the non-stroke group; p=0.06). Diabetes mellitus, triple vessel CAD, number of diseased vessels, chronic total occlusion and previous myocardial infarction were independent predictors of MACCE in patients with prior stroke undergoing PCI. This study demonstrates that, in daily clinical practice, PCI can be provided safely and with good results to patients with a prior ischemic stroke (≥ 3 months).