Severe Stroke Cases Research Articles

The Impact of the COVID-19 Pandemic on the Stroke Unit of a Portuguese Community Hospital.

It is essential to understand the consequences of the COVID-19 pandemic on stroke care, contemplating the potential health and economic consequences of missed diagnoses or treatments. This study examined the pandemic's effects on stroke epidemiology, clinical characteristics, and treatment in a hospital setting, comparing data from March 2020 to February 2021 with the homologous period the previous year. A secondary analysis focused on the state of emergency periods (March 19 to May 2 and November 6 to February 28). The sample included 730 stroke admissions, with 343 during the pandemic. There was a 24.75% reduction in the average daily occupancy rate (p<0.001) and a slight decrease in average daily admissions, especially in June from 132% to 74% (p=0.01). There was a moderate negative correlation between the number of COVID-19 cases and occupancy rates in January (r{s}=-0.422, p=0.01) and February (r{s}=-0.532, p=0.01). Admissions for ischemic stroke decreased by 7.2% (p=0.026), particularly mild events, with a 6.8% decrease in lacunar syndromes (p=0.048). Mechanical thrombectomy (MT) increased by 5.4% (p=0.046), while intravenous thrombolysis (IVT) decreased by 2.8% (p=0.048), especially in severe stroke cases (-21.4%, p=0.001). The pandemic period documented more MT procedures than IVT. Hemorrhagic stroke admissions increased by 6.7% (p=0.01). The analysis suggests a reduction in mild ischemic stroke admissions and fewer patients undergoing IVT for severe strokes during the pandemic. Broader-scale studies are necessary to confirm these findings. Considering the documented decline in diagnosis and treatment, minimizing the impact on stroke care during potential sanitary crises is paramount.

Diurnal variation in quantitative pupillary reactivity in large hemispheric stroke

Background: Pupillary light reflex (PLR) assessment is an important neurological examination reflecting neurological deterioration in severe stroke cases. This study investigated the impact of diurnal variation in the PLR using quantitative pupillometry in stable patients with large hemispheric stroke.Methods: We included 35 patients with large hemispheric stroke without neurological worsening, who were admitted to the neurological intensive care unit between April 2017 and November 2021. Quantitative pupillometry was performed every 4 hours. Pupillometer parameters of maximum pupil size, percentage of constriction (%CH), latency (LAT), constriction velocity (CV), dilation velocity (DV), maximum constriction velocity (MCV), and neurological pupil index (NPi) score were recorded. We evaluated changes in the pupillometer parameters over time using linear mixed model analysis.Results: The diurnal variations revealed that the following parameters were significantly higher at 04:00 than at 20:00: maximum pupil size (right [Rt]: 3.59 vs. 3.21 mm, P&lt;0.001; left [Lt]: 3.51 vs. 3.18 mm, P&lt;0.001), %CH (Rt: 31.48 vs. 25.72, P&lt;0.001; Lt: 31.42 vs. 24.98, P&lt;0.001), CV (Rt: 1.97 vs. 1.68 mm/sec, P&lt;0.001; Lt: 1.98 vs. 1.65 mm/sec, P&lt;0.001), and DV (Rt: 0.97 vs. 0.84 mm/sec, P&lt;0.001; Lt: 0.94 vs. 0.82 mm/sec, P=0.001). However, no significant diurnal variations were observed in the NPi values. Conclusion: Pupillary dynamics based on quantitative pupillometer parameters, including the NPi, demonstrated diurnal variations over 24 hours in large hemispheric stroke patients without neurological worsening. However, all changes in the pupillometer parameters were within normal ranges.

Analysis of Resting Energy Consumption and Its Influencing Factors in Stroke Patients with Severe Neurological Diseases: A Retrospective Clinical Study

Background: This study aimed to observe the changes of resting energy metabolism in patients with severe neurological diseases, and to explore the effects of tracheostomy status, stroke severity, and complications on resting energy expenditure (REE) and respiratory quotient (RQ). Methods: A retrospective study was conducted in 105 patients with neurological rehabilitation who were hospitalized in the Rehabilitation Department of the Affiliated Jiangning Hospital of Nanjing Medical University from August 2018 to October 2021. REE was measured by Italian Cosmed k4b² indirectly, and white blood cell count and C-reactive protein (CRP) were collected. Results: Among the 105 patients, there were 18 cases of mild stroke, 45 cases of moderate stroke, and 42 cases of severe stroke. The difference between predicted REE and actual REE among different degrees of stroke patients was statistically significant (p < 0.05); there was no significant difference in RQ values among different degrees of stroke patients (p > 0.05). Hemoglobin, albumin, and body mass index were significantly and positively correlated with predicted REE and actual REE, while CRP was significantly negatively correlated with predicted REE and actual REE. There was no significant difference in predicted REE, actual REE, and RQ between renal insufficiency, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (p > 0.05). The CRP level could affect the REE of stroke patients. Conclusion: Metabolic vehicle assay has a certain clinical value in accurately evaluating the metabolic needs and feeding level of patients.

TO EVALUATE THE ROLE OF SERUM ALBUMIN AS A PREDICTOR OF FUNCTIONAL OUTCOME OF ACUTE ISCHEMIC STROKE

INTRODUCTION Stroke or cerebrovascular accident is a life threatening neurological disorder. It constitutes more than 50% of admissions in a hospital. Westernization of lifestyle and the resulting demographic transition might increase the burden of stroke even in the developing countries. Albumin is a multifunctional protein which has been proven to have neuroprotective effects in animal studies. There have been several studies in the western world including interventional studies trying to explore the scope of albumin as a neuroprotective agent. Some of these have shown that albumin therapy is capable of minimizing infarction volume and cerebral oedema. Therefore, the present study was conducted to evaluate the role of serum albumin as a predictor of functional outcome of acute ischemic stroke. AIMS &amp; OBJECTIES To determine the correlation between serum albumin level and functional outcome of acute ischemic stroke. MATERIALS &amp; METHODS This prospective, observational study was conducted at district hospital, JamKhambhalia, Dist. Devbhoomi Dwarka. 75 patients admitted with the diagnosis of acute ischemic stroke and meeting the inclusion and exclusion criteria. OBSERVATIONS &amp; RESULTS Most of the cases (58.66%) belonged to the age group of 51 to 70 years. There was a male preponderance. Majority of the cases of minor stroke had serum albumin level of more than 4.5 g/dL, those with moderate stroke had serum albumin of 4.0 to 4.49 g/dL while cases of severe stroke had serum albumin levels of less than 3.0 g/dL; P value: less than 0.001. DISCUSSION Globally, stroke is a leading cause of mortality and disability and there are substantial economic costs for post-stroke care. From the present study, it can be effectively concluded that acute ischemic stroke is prevalent in the older age groups with signicant male preponderance. Hypertension is the most commonly associated co-morbidity. Acute ischemic stroke affects the cerebral arteries more commonly than the cerebellar and lacunar circulation. Middle cerebral artery is the most commonly affected arterial territory. When assessed with the mean serum albumin levels, there was a signicant strong negative correlation with NIHSS score and MRS score. This indicates that low serum albumin levels are associated with increased severity of the stroke and increased/severe disability indicating poor recovery prole.

Assessment of the relation between the neutrophil to lymphocyte ratio and severity of ischemic stroke in a large cohort.

The NLR is a simple and inexpensive parameter that is useful as a marker of subclinical inflammation. The purpose of this study was to investigate the clinical characteristics of patients diagnosed with acute cerebral ischemia at the time of initial evaluation in the emergency department. The study was designed as a multicentre cross-sectional study of acute ischemic stroke patients. Neurological evaluations were assessed using the NIHSS and mRS. Evaluations included the results of patients' laboratory tests performed at the time of presentation to the emergency department. Seven hundred and thirty-five ischemic stroke patients were included in the study. Stroke cases assessed by the mRS as mild or severe showed significant differences with respect to age, leukocyte counts, neutrophil counts, NLR, LDL cholesterol values, and serum glucose values (P=.001). When analysed using NIHSS, lymphocyte levels were significantly higher in very severe stroke cases compared with mild, moderate, and severe cases. NLR was also significantly higher in very severe stroke cases and severe stroke cases as compared with the mild and moderate stroke groups. Neurological evaluations assessed using the mRS showed a mild positive correlation with neutrophil and leukocyte count and a weak correlation with the NLR. The NLR exhibited a significant correlation with the results of the mRS and NIHSS. The NLR measured in the very early period was also significantly associated with clinical condition. These results suggest that high NLR values may be a marker of stroke' severity.What's known Stroke is an important disease that has a significant impact on mortality and morbidity and is closely related to the aging world population. In recent years, highly innovative approaches have been developed in the treatment of stroke. Although a long distance has been covered in the early diagnosis of stroke, the ability to predict the severity of the disease with many parameters is still up to date. What's new At the time of admission, in the absence of infection, parameters such as leukocytelymphocyte count and NLR may be telling about stroke severity. Demonstrating the utility of these simple, practical, inexpensive and naninvasive parameters to predict stroke severity can contribute to the scoring to be established at the time of initial diagnosis.

What Strategy for a Severe Stroke in Africa: Palliative Care or Unreasonable Obstinacy?

Introduction: Palliative care, firstly used for chronic diseases, is currently indicated for some acute pathology such as Stroke. Its implementation improves the quality of care for end-of-life patients. The aim of our study is to report a series of patients who died in the intensive care stroke unit of Brazzaville. Method: It was a descriptive study of a series of 13 cases of severe stroke, admitted to the intensive care unit of the university hospital of Brazzaville, between January 2015 and December 2017. Sociodemographic, clinical, paraclinical and prognostic variables were studied. Result: The mean age of the patients was 46 ± 11.5 years with a male predominance in 69.2% (n = 9). They were all hypertensive. The motor deficit and consciousness disorder association was the reason for admission in 84.6% (n = 11) and an epileptic seizure of 15.4% (n = 2). The mean NIHSS at admission was 21 ± 5, that of Glasgow 6 ± 3. Stroke was hemorrhagic in 84.6% (n = 11) and malignant infarction in 15.4% (n = 2). All of these patients received invasive resuscitation with assisted ventilation and all died within 8 days of admission. Conclusion: The issue of limitation of care deserves to be debated, and is proposed on a case-by-case basis, in the face of a serious stroke. Therapeutic relentlessness is not only expensive, but also raises the problem of suffering of the individual at the end of life.

Antidepressant Use for Improving Functional Ischemic Stroke Outcomes.

ObjectiveTo assess the effect of antidepressants on functional post-stroke recovery, we conducted a retrospective analysis among acute ischemic stroke patients with a subgroup analysis of severe stroke cases, assessing outcomes through 18 months.MethodsA retrospectively gathered ischemic stroke population was obtained from an institutional database. Grouping was via intention-to-treat with antidepressant use post-stroke or lack thereof. Patients with severe stroke (NIHSS ≥ 21) were further analyzed independently. The primary and secondary outcomes were modified Rankin scale (mRS) and survival over 18 months, respectively. Patient demographics and NIHSS were obtained. Data were analyzed in R using adjusted logarithmic-multivariate models. Adjusted Cox proportional hazards models were used to estimate associations between survival and antidepressants.ResultsEight-hundred six patients (52 severe strokes) received antidepressants post-stroke while 948 (56 severe) did not. The antidepressant group was more female (56% to 43.5%) and had significantly better survival rates (88% vs. 79%, HR 0.62, p < 0.01) but not mRS scores (2.13 vs 2.24, p = 0.262) by the end of the study period. Among severe stroke cases, those receiving antidepressants showed better survival rates (79% vs. 60%, HR 0.36, p=0.026) and most recent mRS score (3.9 vs 5, p < 0.01). The analysis controlling for demographics variables retained significance.ConclusionAntidepressant use post-stroke may improve functional outcomes in patients suffering from severe stroke and may decrease all-cause mortality for strokes of any severity.

Evidence for altered upper extremity muscle synergies in chronic stroke survivors with mild and moderate impairment.

Previous studies indicate that motor coordination may be achieved by assembling task-dependent combinations of a few muscle synergies, defined here as fixed patterns of activation across a set of muscles. Our recent study of severely impaired chronic stroke survivors showed that some muscle synergies underlying isometric force generation at the hand are altered in the affected arm. However, whether similar alterations are evident in stroke survivors with lesser impairment remains unclear. Accordingly, we examined muscle synergies underlying spatial patterns of elbow and shoulder muscle activation recorded during an isometric force target matching protocol performed by 16 chronic stroke survivors, evenly divided across mild and moderate impairment levels. We applied non-negative matrix factorization to identify the muscle synergies and compared their structure across groups, including previously collected data from six age-matched control subjects and eight severely impaired stroke survivors. For all groups, EMG spatial patterns were well explained by task-dependent combinations of only a few (typically 4) muscle synergies. Broadly speaking, elbow-related synergies were conserved across stroke survivors, regardless of impairment level. In contrast, the shoulder-related synergies of some stroke survivors with mild and moderate impairment differed from controls, in a manner similar to severely impaired subjects. Cluster analysis of pooled synergies for the 30 subjects identified seven distinct clusters (synergies). Subsequent analysis confirmed that the incidences of three elbow-related synergies were independent of impairment level, while the incidences of four shoulder-related synergies were systematically correlated with impairment level. Overall, our results suggest that alterations in the shoulder muscle synergies underlying isometric force generation appear prominently in mild and moderate stroke, as in most cases of severe stroke, in an impairment level-dependent manner.

Stroke Severity May Impact Speed of Diagnosis &amp; Thrombolysis (P04.058)

Objective: To demonstrate that clinical severity affects speed of diagnosis and treatment of acute ischemic stroke. Background Prior stroke treatment trials demonstrate that earlier thrombolysis leads to greater benefit; however, recent data suggests that less than 1/3 of stroke patients had door-to-needle times Design/Methods: Retrospectively, all acute ischemic stroke patients who received IV rt-PA alone were identified in our stroke database. Patients who received IA rt-PA or mechanical thromboembolectomy were excluded from analysis. Door-to-needle times and NIHSS scores at admission and discharge were identified. Statistical analysis was done using the Mann-Whitney test and a regression model for adjustment of admission NIHSS score severity. Results: IV rt-PA alone was given to 112 AIS patients; 8 lacked discharge NIHSS scores, so 104 were included for analysis. Fifty received IV rt-PA within 60 minutes, 54 after 60 minutes. Mean admission NIHSS scores were 11.2 and 8.8 (p=0.016) for the 60min groups, respectively. The mean improvements in NIHSS scores at discharge were 6.9 and 5.1 (p=0.606), respectively. When the same data set was dichotomized at a target of 80 minutes, the admission scores were 10.6 ( 80min, n=24) (p=0.142). The mean improvements in NIHSS scores for this time dichotomization were 6.8 and 3.0 (p=0.033), respectively. Conclusions: Our experience suggests that greater stroke severity is associated with earlier diagnosis and treatment. When stroke severity on admission is adjusted, the data shows a greater degree of improvement for patients who are treated earlier, confirming prior reports in the literature. Our data may also suggest that less severe stroke cases may present more of a diagnostic challenge, which may delay treatment; however, further review of nation-wide data is necessary to fully answer this question. Disclosure: Dr. Nair has nothing to disclose. Dr. Wang has nothing to disclose. Dr. McNeil has nothing to disclose. Dr. Wang has nothing to disclose. Dr. Jahnel has received personal compensation for activities with Genetech as a Consultant. Dr. Stapel has nothing to disclose. Dr. Stapel has nothing to disclose. Dr. Stapel has nothing to disclose. Dr. Stapel has nothing to disclose. Dr. Beck has nothing to disclose. Dr. Alanis has nothing to disclose. Dr. Talkad has received personal compensation for activities with Genentech, Inc. as a speaker. Dr. Wang has received personal compensation for activities with Sanofi-Aventis Pharmaceuticals, Inc. and Boehringer Ingelheim Pharmaceuticals, Inc.

Clinical study of PTAS therapy for patients with ischemia cerebrovascular disease caused by artery stenosis

The curative efficacy of percutaneous transluminal angioplasty and stenting (PTAS) in the treatment of patients with ischemia cerebrovascular disease caused by artery stenosis was explored. The clinical data of 111 patients with ischemia cerebrovascular disease receiving PTAS in Guangdong Province General Hospital from Aug. 2007 to Nov. 2009 were retrospectively analyzed. In total 132 stents were implanted in the 111 patients. The mortality and rate of neural and non-neural complications were assessed perioperatively. Outcomes [including the frequency of transient ischemic attack (TIA), stroke, or death from vascular diseases) were assessed after operation. NIHSS rating was performed in all cases before and at first week, 6th month and 12th month after the operation. The PTAS success rate was 100%. The degree of stenosis was reduced after PTAS. The total complication rate during perioperative period was 15.3% (the rate of neural complications was 3.6%). Sixty-seven patients were followed up. Three patients (4.48%) developed cerebrovascular events within 1 month, containing one case of TIA, one case of ipsilateral mild stroke and one case of contralateral mild stroke. No severe stroke or death was observed. During a follow-up period of 12 months 7 patients had cerebrovascular events (10.44%), including 2 cases of ipsilateral TIA (2.99%), 2 cases of ipsilateral mild stroke and 2 cases of contralateral mild stroke (2.99%), one case of severe stroke (1.49%). In 13 patients receiving DSA re-examination one year after PTAS, 2 patients (15.38%) had in-stent restenosis. NIHSS scores were obviously decreased during a follow-up period as compared with those pre-operation (P<0.05). It was concluded that PTAS could significantly alleviate the neural function deficit of the patients with ischemia cerebrovascular disease. The success rate of PTAS was high, and the rate of complications was lower and the clinical outcomes were satisfactory. PTAS is a safe and effective therapeutic method, though the long-term outcomes need further study.

Long-term outcome of severe stroke patients: Is the ADL status at discharge from a stroke center indicative of the long-term outcome?

The objective of this study was to examine the possibility of predicting the long-term outcome of severe stroke patients from the ADL status at discharge. The design is a retrospective observational study in the stroke center at Tokushima University Hospital. Severe stroke patients at discharge with Barthel Index (BI) scores ≤ 40 (N=51) were divided into two subgroups retrospectively, improved and unimproved. The Functional Independence Measure (FIM) and BI were analyzed at discharge, 3 and 6 months after onset. Correlation analysis between BI and FIM showed good correlation, especially between BI and motor FIM (mFIM). In conclusion, the ADL status at discharge from a stroke center is not definitely indicative of the long-term outcome, although good recovery of severe stroke cases was observed in males and younger patients, and in patients with motor FIM score>25. This result shows that the first 3 months after the attack should be regarded as an important time window for intensive rehabilitation.

Stroke outcomes in Northern Scotland: does rurality really matter?

Stroke is the third leading cause of death in Scotland after coronary heart disease and cancer and is a major cause of long-term disability. There is evidence in other clinical conditions such as asthma, diabetic retinopathy, and cancer that rural residents may have poorer outcomes, due to relative inaccessibility of health-service provision or because the disease is at a more advanced stage at diagnosis. However, the evidence-base for stroke care and outcomes in remote and rural areas is small and the subject matter is under-researched. This study was designed to examine, over a one-year period, the incidence and outcome of stroke occurring in the Highlands and Islands of Scotland, a large geographical area with many rural and remote settlements. The study explored whether stroke care and outcome was affected by remoteness and rurality. The study was a prospective, community-based, observational survey. Patients in Highland and the Islands (Orkney, Shetland and the Western Isles) suffering first-ever stroke during a 12-month period (from 1 May 2001 to 30 April 2002) were included. All practitioners from health and social care sectors, residential homes, voluntary and charitable organisations were encouraged to notify the researchers of any individual they suspected or knew had a first-ever stroke within the designated time period. Data on 'limitation in activities' (formerly 'level of disability') and service provision were collected using questionnaires and proformas at 1, 3 and 6 months post-stroke from several sources. These included individual patients and carers, health and social care professionals, residential homes, voluntary organisations, and charitable organisations. The analysis focused on location at time of follow up, limitation in activities and service provision. Outcomes were compared across different settlement categories. Settlements were classified as urban/accessible, remote rural and very remote, based on the Scottish Household Survey. In all, 303 patients with a suspected first-ever stroke were notified to the study. The resulting crude incidence of reported stroke was 1.1 per 1000. From the notifications, 239 patients were sent a consent form, of whom 118 agreed to participate in the study. The final dataset, after exclusions for incorrect diagnosis, deaths and other reasons, was derived from 85 patients. Among these, patients from remote rural and very remote settlements were over-represented, when compared to all patients notified. The majority of patients returned home from acute hospitals during the study period and the likelihood of returning home was not related to settlement category. However, a greater proportion of patients in remote rural settlements were admitted to community hospitals and remained there at 6 months. Approximately two-thirds had some degree of disability (or limitation in activities) after their stroke. One-third of patients classed themselves as independent across all time points. Overall, the Barthel Index score increased over time (ie, patients experienced a reduction in disability) with the average score at 1 month post-stroke being 82.5 (range 0-100), at 3 months 85 (range 5-100), and at 6 months 90 (range 5-100). Uptake of services was similar across all settlement categories, with low levels of use at 6-months post-stroke. In particular, few patients used social-support and stroke-specific services, for example Chest, Heart and Stroke Scotland, and Stroke Nurse services. The proportion of patients using any service at 1, 3 and 6 months did not differ between settlement categories. Rural patients did not therefore appear disadvantaged in service provision. The low incidence of reported stroke may have been due to a number of reasons including: death prior to notification; diagnostic uncertainty; stroke severity--failure to notify very mild or very severe stroke cases; and inadequate reporting of patients managed at home. The greater proportion of patients in remote rural settlements being admitted to community hospitals and remaining there at 6 months may reflect greater availability of community hospital places in this settlement category, but may also be influenced by stroke severity. The low uptake of rehabilitation and support services generally, combined with the relatively poor functional outcome of our patients, suggests that there may be an unmet need for rehabilitation. However, rural patients did not appear specifically disadvantaged. Our study indicates that patients developing a first-time stroke in remote and rural areas of the Highlands and Islands of Scotland are not disadvantaged compared to those in urban/accessible areas, with respect to outcome or to the utilization of health and social care services. However, functional outcomes could be improved for patients in all settlement categories.

Provider experience and technical efficiency in the treatment of stroke patients: DEA approach

This study uses Data Envelopment Analysis to examine relationships between provider experience and technical efficiency in stroke treatment patients. Using 214 hospitals grouped according to stroke treatment experience, the study examines how the inputs—average length of stay (ALOS), occupational and physical therapy charges, and all other charges—are combined to treat mild and severe stroke cases. This study finds that, on average, technical efficiency improves with experience. However, although more experienced providers are on average deemed more technically efficient, they tend to have higher charges. The study further illustrates that the gap in case severity between efficient and inefficient providers widens as experience level increases. These findings suggest there is great potential for inefficient providers to alter practice patterns to those similar to efficient providers, in order to significantly reduce aggregate expenditures.

Secular trends in stroke incidence and mortality. The Framingham Study.

The reduction in US stroke mortality has been attributed to declining stroke incidence. However, evidence is accumulating of a trend in declining stroke severity. We examined secular trends in stroke incidence, prevalence, and fatality in Framingham Study subjects aged 55-64 years in three successive decades beginning in 1953, 1963, and 1973. No significant decline in overall stroke and transient ischemic attack incidence or prevalence occurred. In women, but not men, incidence of completed ischemic stroke declined significantly. Stroke severity, however, decreased significantly over time. Stroke with severe neurological deficit decreased in later decades, with a fall in rates of severe stroke cases in which patients were unconscious on admission to the hospital. There was no substantial change in the case mix of infarcts and hemorrhages and no decline in hemorrhage to account for the decline in severity. The proportion of isolated transient ischemic attacks increased significantly over the 30 years studied, yielding an apparent and significant decline in case-fatality rates in men only. Secular trends in stroke incidence and fatality did not follow a clear or definite pattern of decline. While a significant decline in stroke severity occurred over three decades, incidence of infarction fell only in women. The decline in total case fatality rates occurred only in men and resulted largely from an increased incidence of isolated transient ischemic attacks. The severity of completed stroke was significantly lower in the later decades under study.