Stroke Subgroups Research Articles

Identifying Unmet Rehabilitation Needs in Patients After Stroke With a Graphic Rehab-CompassTM

BackgroundUnmet rehabilitation needs are common among stroke survivors. We aimed to evaluate whether a comprehensive graphic “Rehab-Compass,” a novel combination of structured patient-reported outcome measures, was feasible and useful in facilitating a capture of patients' rehabilitation needs in clinical practice. MethodsA new graphic overview of broad unmet rehabilitation needs covers deficits in functioning, daily activity, participation, and quality of life. It was constructed by using 5 patient-oriented, well-validated, and reliable existing instruments with converted data into a 0 (worst outcome) to 100 (best outcome) scale but unchanged in terms of variable properties. Satisfaction of the Rehab-CompassTM was studied by a qualitative interview of 9 patients with stroke and 3 clinicians. Practical feasibility and capacity of the instrument were evaluated in a cross-sectionalstudy with 48 patients at 5-month follow-ups after subarachnoid hemorrhage. ResultsThe Rehab-CompassTM identified and graphically visualized a panoramic view of the multidimensional needs over time which was completed before clinical consultation. The Rehab-CompassTM appeared to be feasible and time-efficientin clinical use. The interviews of both patients and clinicians showed high satisfaction when using the Rehab-CompassTM graph. In the studied stroke patients, the Rehab-CompassTM identified memory and processing information, fatigue, mood, and pain after subarachnoid hemorrhage as the most common problems. ConclusionsThe graphic Rehab-CompassTM seems to be a feasible, useful, and time-saving tool for identification of unmet rehabilitation needs among stroke survivors in clinical practice. Further research is needed to make the Rehab-CompassTM more concise and evaluate the instrument among different stroke subgroups.

Differential leukocyte counts on admission predict outcomes in patients with acute ischaemic stroke treated with intravenous thrombolysis

To determine the association of differential leukocyte counts on admission with efficacy and safety outcomes in patients with acute ischaemic stroke (AIS) treated with intravenous thrombolysis (IVT). Consecutive patients with AIS receiving IVT were evaluated at two stroke centers. Differential leukocyte counts and neutrophil:lymphocyte ratio (NLR) were determined during the initial 12 h of admission. Efficacy outcomes were favorable functional outcome (FFO) (modified Rankin Scale scores of 0-1) and functional independence (FI) (modified Rankin Scale scores of 0-2) at 3 months, whereas safety outcomes were symptomatic intracranial hemorrhage and 3-month mortality. Among 657 IVT-treated patients with AIS, the mean age was 64 ± 14 years, 50% were female and median National Institutes of Health Stroke Scale score was 7 points (interquartile range, 4-13). Lower neutrophil and leukocyte counts and NLR counts were observed in patients with 3-month FFO and FI, whereas higher counts were observed in patients who died at 3 months. The best discriminative factors for 3-month FFO and FI were NLR < 2.2 (sensitivity 51.4%, specificity 63.1%) and leukocyte count <8100/μL (sensitivity 57.5%, specificity 55.1%), respectively. After adjustment for potential confounders, NLR < 2.2 was associated with higher odds of FFO [odds ratio (OR), 1.56; 95% confidence interval (CI), 1.08-2.24; P = 0.018], whereas leukocyte count <8100/μL demonstrated higher odds of 3-month FI (OR, 1.69; 95% CI, 1.11-2.57; P = 0.014) and lower odds of 3-month mortality (OR, 0.31; 95% CI, 0.16-0.60; P = 0.001). Combined neutrophil (<6800/μL) and leukocyte (<8100/μL) counts demonstrated a strong interaction for 3-month FI (OR, 1.73; 95% CI, 1.13-2.67; P interaction = 0.012). Differential leukocyte counts on admission were independently associated with clinical outcomes in patients with AIS treated with IVT. These inflammatory biomarkers are potential targets for adjunctive neuroprotection in this stroke subgroup.

Although non-stroke outcomes are more common, stroke risk scores can be used for prediction in patients with atrial fibrillation

BackgroundWe investigated whether cardiovascular outcome patterns differ across atrial fibrillation (AF) subgroups defined by age, valvular status, newly diagnosed vs. prevalent cases, or anticoagulation status, and whether stroke risk models can accurately predict non-stroke outcomes. Methods and resultsWe performed a retrospective cohort study of all 147,952 adults with AF in Alberta, Canada between January 2008 and March 2014: 23,095 (15.6%) had at least one thromboembolic event (stroke, TIA, or systemic embolism) and 52,618 (35.6%) had a non-stroke major adverse cardiovascular events (NS-MACE = all-cause mortality, new heart failure, new acute coronary syndrome) during follow-up (median 46 months). NS-MACE were 2–3 times more frequent than stroke in all subgroups. Newly diagnosed patients had higher rates of all outcomes in the first year than those with prevalent AF (and those with valvular AF had the highest rates): incident vs. prevalent NS-MACE rates per 100 patient years were 53.1 vs. 23.2 for anticoagulated valvular AF patients, 32.8 vs. 11.0 for non-anticoagulated NVAF patients, and 29.6 vs. 14.6 for anticoagulated NVAF patients. In non-anticoagulated NVAF patients, the stroke risk models exhibited similar accuracy for prediction of NS-MACE as they did for stroke prediction: C-statistics 0.66 [0.66–0.66] vs. 0.67 [0.66–0.68] for ATRIA-STROKE, 0.66 [0.66–0.67] vs. 0.62 [0.61–0.62] for CHADS2, and 0.62 [0.61–0.62] vs. 0.52 [0.51–0.52] for CHA2DS2-VASc. ConclusionsNon-stroke cardiovascular outcomes are more common than stroke in all AF subgroups but current stroke risk scores exhibit similar (modest) ability to predict risk for NS-MACE as for stroke, allowing identification of high-risk individuals for intervention.

Argatroban plus aspirin versus aspirin in acute ischemic stroke

ABSTRACTObjectives: Anticoagulant therapy in the acute phase of AIS remains controversial. The aim of this study was to investigate whether argatroban benefited early stroke outcomes compared with antiplatelet treatment.Methods: We reviewed data from 1,485 patients with AIS hospitalized at Tianjin Union Medical Center (TUMC) between 1 January 2013 and 31 December 2015 from the TUMC registry database. Patients were divided into two groups: an antiplatelet group (aspirin 300 mg daily) and an argatroban group (argatroban 60 mg for 2 days followed by 20 mg daily; or 20 mg daily – both regimens combination with aspirin 100 mg daily). Two primary outcomes, change in NIHSS score (baseline–discharge) and intracerebral hemorrhage, were investigated.Results: No major symptomatic intracerebral hemorrhages were observed in either group. Both groups had significantly decreased NIHSS scores at discharge (Z = −14.617, P < 0.001 and Z = −6.385, P < 0.001, respectively), and there were no significant group differences in NIHSS score change (Z = −1.888, P = 0.059). In the mild stroke subgroup, the argatroban group had a worse NIHSS score at discharge (Z = −6.148, P = 0.002), while the aspirin group had an improved NIHSS score (Z = −4,423, P < 0.001). In the moderate stroke subgroup, both groups had significantly decreased NIHSS scores at discharge (Z = −13.260, P < 0.001 and Z = −7.108, P < 0.001, respectively) and there were no significant group differences in NIHSS score changes (Z = −1.888, P = 0.059).Conclusion: Argatroban is effective and safe for the treatment of moderate AIS with similar efficacy to high-dose aspirin in the acute phase of AIS, although no additional benefit on short-term outcome was observed. For patients with mild AIS, argatroban may be inferior to high-dose aspirin.

Horizontal gaze deviation on computed tomography: the visual criterion and lesion characteristics in ischemic stroke.

Horizontal gaze deviation (HGD) on computed tomography (CT) is considered a useful finding for detecting ischemic stroke. To enhance its availability, we studied the criterion suitable for visual determination and lesion characteristics. The clinical records of 327 ischemic stroke patients and 193 non-stroke controls were reviewed with measurements of eye deviation angles on CT. Initially, the HGD criterion defined by the minimum angle in unidirectionally deviated eyes was determined from control data. Subsequently, patients were classified by infarcted arterial territory and stroke subtype, and compared with controls in HGD frequency using Fisher's exact test. In patients with middle cerebral artery (MCA) stroke, ipsilesional HGD during a week from symptom onset was modeled in a mixed-effects logistic regression analysis. Among the controls, 4.9% were categorized as pathological with a cutoff of 14°. HGD frequency was significantly increased in most stroke subgroups and prominent in MCA cardioaortic embolism (odds ratio and 95% confidence interval, 24.2 [9.6, 66.3]) and posterior inferior cerebellar artery (PICA) stroke (15.6 [3.2, 76.2]). In MCA stroke, ipsilesional HGD probability decreased daily (0.62 [0.48, 0.78]) and increased with cardioaortic embolism (4.12 [1.05, 16.16]) and lenticular nucleus lesions (3.36 [1.18, 9.58]). HGD is judged pathological if both eyes are unidirectionally deviated by ≥ 14°. This CT sign is frequent in MCA cardioaortic embolism and PICA stroke but does not necessarily indicate specific lesions. In MCA stroke, HGD is influenced by time, stroke subtype, and lesion location. The criterion and basic information on lesion characteristics may enhance the availability of HGD.

The middle-term outcome of carotid endarterectomy and stenting for treatment of ischemic stroke in Chinese patients

This study aims to investigate the complication and middle-term outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in Chinese patients, which was a retrospective case-control study and perioperative complications and 2-year end points were analyzed. Follow-up was done by a certified doctor, and restenosis was detected by ultrasound. Operation success rate were 100% in two groups. CAS showed the higher incidence rate of all stroke/TIA at 30days post-procedure (7.89% VS 1.85%, P = 0.038), odds ratio (OR) with 95% confidence interval, 4.54 (1.09–18.97), but there was no difference in the incidence rate of stroke subgroups, mortality and myocardial infarction between two groups. The higher incidence of hypertension with CEA (14.42% VS 5.26%, P = 0.012), OR: 2.90 (1.26–6.65) and hypotension with CAS (14.91% VS 1.85%, P = 0.001), OR: 0.11 (0.03–0.42). No difference in all stroke, ipsilateral stroke and mortality between two groups at 24 months post-procedures, however, the total incidence rate of stroke/death was higher in CAS (12.84% VS 4.72%, P = 0.036), OR: 2.98 (1.08,8.23). Higher restenosis rate of CAS was examined (13.76% VS 5.66%, P = 0.045), OR: 2.66 (1.02, 6.74). CAS and CEA showed a similar middle-term outcome, but CAS showed a higher incidence rate of stroke and restenosis after operation.

Serum matrix metalloproteinase-8, tissue inhibitor of metalloproteinase and myeloperoxidase in ischemic stroke

Background and aimsMatrix metalloproteinase (MMP)-8 and myeloperoxidase (MPO) may contribute to cerebral damage in acute ischemic stroke. We tested the hypothesis that levels of MPO, MMP-8 and the ratio between MMP-8 and its regulator, tissue inhibitor of metalloproteinase (TIMP-1), are increased in acute ischemic stroke and its etiologic subgroups and they correlate with stroke severity. MethodsIn a cross-sectional case–control study, serum concentrations of MMP-8, MPO and TIMP-1 were assessed within 24 h after admission in 470 first-ever ischemic stroke patients and 809 age- and sex-matched controls, randomly selected from the population. Odds ratios (OR) per decade of log transformed dependent variables were calculated and adjusted for age, sex and vascular risk factors. ResultsLevels of MMP-8 (OR 4.9; 95% CI 3.4–7.2), MMP-8/TIMP-1 ratio (3.0; 2.2–4.1) and MPO (6.6; 4.0–11.0) were independently associated with ischemic stroke. MMP-8 levels differed between etiologic stroke subgroups (p = 0.019, ANOVA), with higher levels in cardioembolic stroke and stroke due to large vessel disease, and lower levels in microangiopathic stroke. MMP-8, MMP-8/TIMP-1 ratio and MPO (p < 0.001) concentrations showed positive associations with stroke severity independent of stroke etiology. ConclusionsConcentrations of serum neutrophil markers are increased after ischemic stroke and associate with stroke severity and etiology. The value of these biomarkers in diagnostics and prognostics is worth being evaluated.

Diagnostic Error in Stroke-Reasons and Proposed Solutions.

We discuss the frequency of stroke misdiagnosis and identify subgroups of stroke at high risk for specific diagnostic errors. In addition, we review common reasons for misdiagnosis and propose solutions to decrease error. According to a recent report by the National Academy of Medicine, most people in the USA are likely to experience a diagnostic error during their lifetimes. Nearly half of such errors result in serious disability and death. Stroke misdiagnosis is a major health care concern, with initial misdiagnosis estimated to occur in 9% of all stroke patients in the emergency setting. Under- or missed diagnosis (false negative) of stroke can result in adverse patient outcomes due to the preclusion of acute treatments and failure to initiate secondary prevention strategies. On the other hand, the overdiagnosis of stroke can result in inappropriate treatment, delayed identification of actual underlying disease, and increased health care costs. Young patients, women, minorities, and patients presenting with non-specific, transient, or posterior circulation stroke symptoms are at increased risk of misdiagnosis. Strategies to decrease diagnostic error in stroke have largely focused on early stroke detection via bedside examination strategies and a clinical decision rules. Targeted interventions to improve the diagnostic accuracy of stroke diagnosis among high-risk groups as well as symptom-specific clinical decision supports are needed. There are a number of open questions in the study of stroke misdiagnosis. To improve patient outcomes, existing strategies to improve stroke diagnostic accuracy should be more broadly adopted and novel interventions devised and tested to reduce diagnostic errors.

Managing high blood pressure during acute ischemic stroke and intracerebral hemorrhage.

Blood pressure (BP) elevations above premorbid levels are observed in at least 60% of acute ischemic and hemorrhagic stroke patients, within the first 24 h of symptom onset. A number of potential causes have been hypothesized, and high BP may be associated with poor stroke outcome. This review discusses management strategies of high BP in acute stroke, in the context of current guidelines. Excessive BP elevation can impact acute stroke therapeutic strategies, particularly in modifying intervention safety and efficacy. Currently, guidance on BP management in acute ischemic stroke and intracerebral hemorrhage (ICH) exists in a limited number of specific clinical presentations, including spontaneous ICH and continuing versus stopping preexisting antihypertensive therapy. However, ongoing clinical trials will further investigate the safety and efficacy of urgent BP-lowering therapy for other indications. There are clear national and international guidelines on BP lowering for specific indications, as well as ongoing clinical trials aiming to address common clinical scenarios in which the evidence-base is lacking and uncertain. This is specifically in important stroke subgroups previously excluded from trials, patients requiring mechanical thrombectomy and nonvitamin K antagonist-associated ICH reversal.

Abstract TMP48: Subcortical Volumes Associated With Post-Stroke Motor Performance Vary Across Impairment Severity, Time Since Stroke, and Lesion Laterality: an ENIGMA Stroke Recovery Analysis

Associations between subcortical gray matter volume and motor performance post-stroke are unclear, partly because many stroke MRI studies are underpowered. Potential influences of the severity of motor impairment, lesion laterality, and time since stroke on these associations is also unknown. Here, we addressed these questions using a large dataset (n=629) from the ENIGMA Stroke Recovery working group (http://enigma.usc.edu). Regression analyses examined brain volumes as predictors of motor scores. ENIGMA FreeSurfer protocols extracted volumes from 16 subcortical regions on T1-weighted MRIs; segmentations were manually quality controlled. Motor scores were calculated as a percentage of the maximum possible score (100% = no impairment). Covariates (e.g., age, sex, intracranial volume) were modeled. Statistical significance was assessed nonparametrically by permutation. Separate analyses were performed, stratifying by motor severity and time since stroke. Each analysis was also subdivided by lesioned hemisphere. The motor severity analysis (Table 1A) used subgroups of mild (66.7-99.9%), moderate (33.3-66.6%), and severe (0-33.2%). Significant associations were found for mild and moderate, but not severe, stroke; only the left hemisphere stroke group showed further significant results. The time since stroke analysis (Table 1B) used subgroups of acute (&lt;1 month), subacute (1-6 months), and chronic (&gt;6 months). Significant associations were found in chronic stroke, but not acute, subacute. Left versus right hemisphere lesions generated different results in chronic stroke. Overall, these results show that the most significant associations between subcortical volumes and motor outcomes are in chronic mild-to-moderate stroke. Stroke subgroups may recover via disparate mechanisms; establishing biomarkers of impairment and disability across stroke subgroups may be useful for clinical trials.

Non-alcoholic fatty liver disease is associated with stroke severity and progression of brainstem infarctions.

Non-alcoholic fatty liver disease (NAFLD) is closely correlated to visceral obesity, dyslipidaemia, insulin resistance and type 2 diabetes mellitus. We sought to assess the association between a specific stroke subgroup, brainstem infarctions (BSIs) and NAFLD. Furthermore, we evaluated whether NAFLD is an independent risk factor in patients with BSIs. Non-alcoholic fatty liver disease was assessed in 306 patients with radiologically confirmed BSIs via liver ultrasound. Differences between patients with and without NAFLD were compared. Data associated with stroke severity and progression after admission were collected. Non-alcoholic fatty liver disease was found in 130 (42.5%) patients with acute BSIs; 58 (19.0%) had National Institutes of Health Stroke Scale scores >7 and 57 (18.6%) had progression after admission. Initial National Institutes of Health Stroke Scale scores, incidence of progression and stroke severity, and modified Rankin Scale scores at discharge were significantly higher in patients with NAFLD than in those without NAFLD. NAFLD was associated with stroke severity [Cox regression: hazard ratio (HR), 2.243; 95% confidence interval (CI), 1.254-4.013, P < 0.01]. This risk remained statistically significant after controlling for age, gender, diabetes mellitus and C-reactive protein (HR, 2.327; 95% CI, 1.252-4.324, P < 0.01). In addition, NAFLD was associated with progression (HR, 2.155; 95% CI, 1.201-3.865, P < 0.05) and remained significant after controlling for age, gender, diabetes mellitus, fibrinogen and C-reactive protein (HR, 2.378; 95% CI, 1.260-4.486, P < 0.01). These results suggest that NAFLD is a potential risk factor when evaluating the severity and progression of acute BSIs. This relationship is independent of classic risk factors and metabolic syndrome features.

Altered functional connectivity differs in stroke survivors with impaired touch sensation following left and right hemisphere lesions.

One in two survivors experience impairment in touch sensation after stroke. The nature of this impairment is likely associated with changes associated with the functional somatosensory network of the brain; however few studies have examined this. In particular, the impact of lesioned hemisphere has not been investigated. We examined resting state functional connectivity in 28 stroke survivors, 14 with left hemisphere and 14 with right hemisphere lesion, and 14 healthy controls. Contra-lesional hands showed significantly decreased touch discrimination. Whole brain functional connectivity (FC) data was extracted from four seed regions, i.e. primary (S1) and secondary (S2) somatosensory cortices in both hemispheres. Whole brain FC maps and Laterality Indices (LI) were calculated for subgroups. Inter-hemispheric FC was greater in healthy controls compared to the combined stroke cohort from the left S1 seed and bilateral S2 seeds. The left lesion subgroup showed decreased FC, relative to controls, from left ipsi-lesional S1 to contra-lesional S1 and to distributed temporal, occipital and parietal regions. In comparison, the right lesion group showed decreased connectivity from contra-lesional left S1 and bilateral S2 to ipsi-lesional parietal operculum (S2), and to occipital and temporal regions. The right lesion group also showed increased intra-hemispheric FC from ipsi-lesional right S1 to inferior parietal regions compared to controls. In comparison to the left lesion group, those with right lesion showed greater intra-hemispheric connectivity from left S1 to left parietal and occipital regions and from right S1 to right angular and parietal regions. Laterality Indices were significantly greater for stroke subgroups relative to matched controls for contra-lesional S1 (left lesion group) and contra-lesional S2 (both groups). We provide evidence of altered functional connectivity within the somatosensory network, across both hemispheres, and to other networks in stroke survivors with impaired touch sensation. Hemisphere of lesion was associated with different patterns of altered functional connectivity within the somatosensory network and with related function was associated with different patterns of altered functional connectivity within the somatosensory network and with related functional networks.

Role of Hyperintense Acute Reperfusion Marker for Classifying the Stroke Etiology.

The hyperintense acute reperfusion marker (HARM) is a delayed enhancement of the subarachnoid or subpial space observed on post-contrast fluid-attenuated inversion recovery (FLAIR) images and is associated with permeability changes to the blood-brain barrier in acute stroke. We investigated the relationship between HARM and stroke etiology based on the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. In addition, we evaluated the relationship between HARM and stroke locations with respect to vascular territories and anatomic compartments. We recruited 264 consecutive patients (109 women; mean age 68.63 years) who were diagnosed with acute ischemic stroke and underwent brain magnetic resonance imaging (MRI) including post-contrast FLAIR and DWI within 7 days of symptom onset from May 2015 to March 2016 for this retrospective study. Post-contrast FLAIR images were obtained 5 min after gadolinium administration. The mean time interval between the onset of stroke symptoms and MRI acquisition in total included patients was 18 h and 7 min (median 12 h and 57 min, range 2-127 h). We analyzed the overall incidence and distribution patterns of HARM in acute ischemic stroke cases and compared the relative incidence and distribution patterns of HARM between the subgroups of stroke etiology based on conventional TOAST classification. We obtained odds ratio (OR) of HARM in different stroke locations based on vascular territories and anatomical compartments. This study was approved by our institutional review board. Among the 264 patients, 67 (25.38%) patients were HARM positive and 197 (74.62%) patients were HARM negative. There was significant difference in HARM incidence among the stroke subgroups (p < 0.001). Small vessel occlusion (SVO) was associated with the HARM-negative group (p < 0.001), while large artery atherosclerosis (LAA) and cardioembolism (CE) were associated with the HARM-positive group (p = 0.001). Also, regional pattern of HARM on the same vascular territory as the acute infarction was dominantly demonstrated regardless of stroke etiology. The OR for HARM from middle cerebral artery (MCA) infarction was 1.868 [95% confidence interval (CI): 1.025-3.401]. The OR for HARM from cortical infarction was 9.475 (95% CI: 4.754-18.883) compared to other anatomic compartments. The presence of the HARM was significantly associated with embolic infarctions including LAA and CE. Conversely, SVO was exclusively associated with the absence of the HARM. Second, MCA and cortical infarction showed a more pronounced HARM compared to infarctions at other vascular territories and anatomic compartments. According to the results in the current study, we speculate that the presence of HARM on post-contrast FLAIR images was associated with specific stroke causes especially in embolic causes.

Mechanical Thrombectomy for Minor and Mild Stroke Patients Harboring Large Vessel Occlusion in the Anterior Circulation

Proximal large vessel occlusion (LVO) is present in up to 30% of minor strokes. The effectiveness of mechanical thrombectomy (MT) in the subgroup of minor stroke with LVO in the anterior circulation is still open to debate. Data about MT in this subgroup of patients are sparse, and their optimal management has not yet been defined. The purpose of this multicenter cohort study was to evaluate the effectiveness of MT in patients experiencing acute ischemic stroke (AIS) because of LVO in the anterior circulation, presenting with minor-to-mild stroke symptoms (National Institutes of Health Stroke Scale score of <8). Multicenter cohort study involving 4 comprehensive stroke centers having 2 therapeutic approaches (urgent thrombectomy associated with best medical treatment [BMT] versus BMT first and MT if worsening occurs) about management of patients with minor and mild acute ischemic stroke harboring LVO in the anterior circulation. An intention-to-treat analysis was conducted. The primary end point was the rate of excellent outcome defined as the achievement of a modified Rankin Scale score of 0 to 1 at 3 months. Three hundred one patients were included, 170 with urgent MT associated with BMT, and 131 with BMT alone as first-line treatment. Patients treated with MT were younger, more often received intravenous thrombolysis, and had shorter time to imaging. Twenty-four patients (18.0%) in the medical group had rescue MT because of neurological worsening. Overall, excellent outcome was achieved in 64.5% of patients, with no difference between the 2 groups. Stratified analysis according to key subgroups did not find heterogeneity in the treatment effect size. Minor-to-mild stroke patients with LVO achieved excellent and favorable functional outcomes at 3 months in similar proportions between urgent MT versus delayed MT associated with BMT. There is thus an urgent need for randomized trials to define the effectiveness of MT in this patient subgroup.

Renal impairment in stroke patients: A comparison between the haemorrhagic and ischemic variants.

Background: Renal impairment is regularly seen in hospitalized stroke patients, affecting the outcome of patients, as well as causing difficulties in their management. A prospective cohort study was conducted to assess the trend of renal function in hospitalized ischemic and haemorrhagic stroke patients. The incidence of renal impairment in these subgroups, the contributing factors and the need for renal replacement in renal impaired patients was evaluated. Methods: Alternate day renal function testing was performed in hospitalized stroke patients. Estimated glomerular filtration rate (e-GFR) was calculated and the trend of renal function in the two stroke subgroups (haemorrhagic and ischemic) was assessed, with renal impairment defined as e-GFR < 60mL/ minute per 1.73m 2. Results: Among 52 patients, 25 had haemorrhagic stroke (mean age 59.81 ± 14.67) and 27 had ischemic stroke (mean age 56.12 ± 13.08). The mean e-GFR (mL/minute per 1.732m 2) at admission in the haemorrhagic stroke subgroup was 64.79 ± 25.85 compared to 86.04 ± 26.09 in the ischemic stroke subgroup (p=0.005). Sixteen out of 25 (64%) patients in the haemorrhagic stroke subgroup and 9 out of 27 (33.3%) patients in the ischemic subgroup developed renal impairment (p=0.027). The location of the bleed (p=0.8), volume of hematoma (p=0.966) and surgical intervention (p=0.4) did not predispose the patients to renal impairment. One out of 16 patients with haemorrhagic stroke (who eventually died), and 2 out of 9 patients with ischemic stroke required renal replacement. Conclusion: Renal impairment is commonly seen in stroke patients, more so in patients who suffered haemorrhagic strokes. The impairment, however, is transient and rarely requires renal replacement therapy.

Renal impairment in stroke patients: A comparison between the haemorrhagic and ischemic variants

Background: Renal impairment is regularly seen in hospitalized stroke patients, affecting the outcome of patients, as well as causing difficulties in their management. A prospective cohort study was conducted to assess the trend of renal function in hospitalized ischemic and haemorrhagic stroke patients. The incidence of renal impairment in these subgroups, the contributing factors and the need for renal replacement in renal impaired patients was evaluated. Methods: Alternate day renal function testing was performed in hospitalized stroke patients. Estimated glomerular filtration rate (e-GFR) was calculated and the trend of renal function in the two stroke subgroups (haemorrhagic and ischemic) was assessed, with renal impairment defined as e-GFR < 60mL/ minute per 1.73m 2. Results: Among 52 patients, 25 had haemorrhagic stroke (mean age 59.81 ± 14.67) and 27 had ischemic stroke (mean age 56.12 ± 13.08). The mean e-GFR (mL/minute per 1.732m 2) at admission in the haemorrhagic stroke subgroup was 64.79 ± 25.85 compared to 86.04 ± 26.09 in the ischemic stroke subgroup (p=0.005). Sixteen out of 25 (64%) patients in the haemorrhagic stroke subgroup and 9 out of 27 (33.3%) patients in the ischemic subgroup developed renal impairment (p=0.027). The location of the bleed (p=0.8), volume of hematoma (p=0.966) and surgical intervention (p=0.4) did not predispose the patients to renal impairment. One out of 16 patients with haemorrhagic stroke (who eventually died), and 2 out of 9 patients with ischemic stroke required renal replacement. Conclusion: Renal impairment is commonly seen in stroke patients, more so in patients who suffered haemorrhagic strokes. The impairment, however, is transient and rarely requires renal replacement therapy.

Investigating Real-World Clopidogrel Pharmacogenetics in Stroke Using a Bioresource Linked to Electronic Medical Records.

Clopidogrel efficacy is influenced by genetic variation of cytochrome P450 (CYP)2C19, however, few studies have considered patients who have a stroke. We used electronic medical records (EMRs) linked to a bioresource to examine real‐world implications of clopidogrel pharmacogenetics in stroke. Patients hospitalized for any arterial thrombo‐occlusive (ATO) event who subsequently redeemed clopidogrel prescriptions in the community were entered into the study (n = 651). During 24‐month follow‐up, the primary endpoint of recurrent ATO or death occurred in 299 patients (46%). CYP2C19*2 loss‐of‐function allele carriers had an increased risk (hazard ratio (HR) = 1.29; 95% confidence interval (CI) = 1.04–1.59; P = 0.019). In the ischemic stroke subgroup (n = 94), the estimate of risk was greater (HR = 2.23; 95% CI = 1.17–4.24; P = 0.015), which was further supported by a meta‐analysis of available studies. In conclusion, we have demonstrated the clinical impact of CYP2C19*2 on clopidogrel efficacy using a purely EMR approach. This suggests that the risk in the ischemic stroke population may be particularly high.

Renal impairment in stroke patients: A comparison between the haemorrhagic and ischemic variants.

Background: Renal impairment is regularly seen in hospitalized stroke patients, affecting the outcome of patients, as well as causing difficulties in their management. A prospective cohort study was conducted to assess the trend of renal function in hospitalized ischemic and haemorrhagic stroke patients. The incidence of renal impairment in these subgroups, the contributing factors and the need for renal replacement in renal impaired patients was evaluated. Methods: Alternate day renal function testing was performed in hospitalized stroke patients. Estimated glomerular filtration rate (e-GFR) was calculated and the trend of renal function in the two stroke subgroups (haemorrhagic and ischemic) was assessed, with renal impairment defined as e-GFR < 60mL/ minute per 1.73m 2. Results: Among 52 patients, 25 had haemorrhagic stroke (mean age 59.81 ± 14.67) and 27 had ischemic stroke (mean age 56.12 ± 13.08). The mean e-GFR (mL/minute per 1.732m 2) at admission in the haemorrhagic stroke subgroup was 64.79 ± 25.85 compared to 86.04 ± 26.09 in the ischemic stroke subgroup (p=0.005). Sixteen out of 25 (64%) patients in the haemorrhagic stroke subgroup and 9 out of 27 (33.3%) patients in the ischemic subgroup developed renal impairment (p=0.27). The location of the bleed (p=0.8), volume of hematoma (p=0.966) and surgical intervention (p=0.4) did not predispose the patients to renal impairment. One out of 16 patients with haemorrhagic stroke (who eventually died), and 2 out of 9 patients with ischemic stroke required renal replacement. Conclusion: Renal impairment is commonly seen in stroke patients, more so in patients who suffered haemorrhagic strokes. The impairment, however, is transient and rarely requires renal replacement therapy.

Novel CD137 Gene Polymorphisms and Susceptibility to Ischemic Stroke in the Northern Chinese Han Population.

Ischemic stroke is a leading cause of mortality and morbidity worldwide, and atherosclerosis is one of the major risk factors for this neurologic deficit. Recent studies have revealed the important role of CD137 in human atherosclerosis. Here, we analyzed the association of CD137 single nucleotide polymorphisms (SNPs) with ischemic stroke. We assessed three SNPs (rs161827, rs161818, and rs161810) of the CD137 gene and their association with ischemic stroke in a northern Chinese Han population. A total of 496 ischemic stroke patients and 486 gender-matched control subjects were genotyped. We classified these patients according to complications with diabetes and hypertension and also by ischemic stroke subtypes. Allele, genotype, and haplotype association studies were tested in all patients and subgroups. We used multivariable logistic regression analysis combined with 10,000 permutations to analyze the association of CD137 polymorphisms with ischemic stroke. After adjusting for relevant factors, rs161827 was significantly different between patients with and without diabetes and the control group (p=0.0001, p=0.014, and p=0.0001, respectively). In addition, rs161818 and rs161810 differed significantly between patients without diabetes and the control subjects (p=0.0001 and p=0.004, respectively). rs161827, rs161818, and rs161810 were all statistically significant among the combination stroke subgroup compared with the controls. These results indicate that the CD137 gene is associated with risk of ischemic stroke in the northern Han Chinese. Moreover, CD137 gene polymorphism may be one mediating factor between diabetes and ischemic stroke.

Early supported discharge services for people with acute stroke.

People with stroke conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed that offer people in hospital an early discharge with rehabilitation at home (early supported discharge: ESD). To establish if, in comparison with conventional care, services that offer people in hospital with stroke a policy of early discharge with rehabilitation provided in the community (ESD) can: 1) accelerate return home, 2) provide equivalent or better patient and carer outcomes, 3) be acceptable satisfactory to patients and carers, and 4) have justifiable resource implications use. We searched the Cochrane Stroke Group Trials Register (January 2017), Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1) in the Cochrane Library (searched January 2017), MEDLINE in Ovid (searched January 2017), Embase in Ovid (searched January 2017), CINAHL in EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to December 2016), and Web of Science (to January 2017). In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists. Randomised controlled trials (RCTs) recruiting stroke patients in hospital to receive either conventional care or any service intervention that has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care. The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials, categorised them on their eligibility and extracted data. Where possible we sought standardised data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. We assessed risk of bias for the included trials and used GRADE to assess the quality of the body of evidence. We included 17 trials, recruiting 2422 participants, for which outcome data are currently available. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The ESD group showed reductions in the length of hospital stay equivalent to approximately six days (mean difference (MD) -5.5; 95% confidence interval (CI) -3 to -8 days; P < 0.0001; moderate-grade evidence). The primary outcome was available for 16 trials (2359 participants). Overall, the odds ratios (OR) for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was OR 0.80 (95% CI 0.67 to 0.95, P = 0.01, moderate-grade evidence) which equates to five fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials; 2116 participants) and death or requiring institutional care (12 trials; 1664 participants) were OR 1.04 (95% CI 0.77 to 1.40, P = 0.81, moderate-grade evidence) and OR 0.75 (95% CI 0.59 to 0.96, P = 0.02, moderate-grade evidence), respectively. Small improvements were also seen in participants' extended activities of daily living scores (standardised mean difference (SMD) 0.14, 95% CI 0.03 to 0.25, P = 0.01, low-grade evidence) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02, low-grade evidence). We saw no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. We found low-quality evidence that the risk of readmission to hospital was similar in the ESD and conventional care group (OR 1.09, 95% CI 0.79 to 1.51, P = 0.59, low-grade evidence). The evidence for the apparent benefits were weaker at one- and five-year follow-up. Estimated costs from six individual trials ranged from 23% lower to 15% greater for the ESD group in comparison to usual care.In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without a co-ordinated team (subgroup interaction at P = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (subgroup interaction at P = 0.04). Appropriately resourced ESD services with co-ordinated multidisciplinary team input provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. Results are inconclusive for services without co-ordinated multidisciplinary team input. We observed no adverse impact on the mood or subjective health status of patients or carers, nor on readmission to hospital.