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Neurologic symptom severity after a recent noncardioembolic stroke and recurrent vascular risk.

ABSTRACT: There is a well-established relation of symptom severity with functional status and mortality after an index stroke. However, little is known about the impact of symptom severity of a recent index stroke on risk of recurrent vascular events.We reviewed the data set of a multicenter trial involving 3680 recent noncardioembolic stroke patients aged 35 years or older and followed for 2 years. Independent associations of stroke severity (as measured by National Institutes of Health Stroke Scale [NIHSS] score) with recurrent stroke (primary outcome) and stroke/coronary heart disease (CHD)/vascular death (secondary outcome) were analyzed. NIHSS score was analyzed as a dichotomous (<4 versus ?4) and a continuous variable.Among study subjects, 550 (15%) had NIHSS scores of 4 or more (overall scores ranged from 0 to 18, median score was 1 [25th-75th percentile 0-2]). NIHSS was measured at a median of 35 days after the index stroke. After adjusting for multiple covariates, NIHSS of 4 or more was independently linked to a higher risk of recurrent stroke (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.01-1.84) and risk of stroke/CHD/vascular death (HR, 1.32; 95% CI, 1.07-1.64). Analysis of NIHSS score as a continuous variable also showed a higher risk of recurrent stroke (HR, 1.06; 95% CI, 1.00-1.12) and stroke/CHD/vascular death (HR, 1.05; 95% CI, 1.01-1.09) with increasing index stroke symptom severity.Greater residual symptom severity after a recent stroke is associated with higher risk of recurrent vascular events. Future studies are needed to confirm this relationship and to clarify its underlying mechanisms.

SUBMITTER: Park JH

PROVIDER: S-EPMC4408262 | biostudies-literature | 2015 May

REPOSITORIES: biostudies-literature

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Neurologic symptom severity after a recent noncardioembolic stroke and recurrent vascular risk.

Park Jong-Ho JH Ovbiagele Bruce B

Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 20150325 5

<h4>Background</h4>There is a well-established relation of symptom severity with functional status and mortality after an index stroke. However, little is known about the impact of symptom severity of a recent index stroke on risk of recurrent vascular events.<h4>Methods</h4>We reviewed the data set of a multicenter trial involving 3680 recent noncardioembolic stroke patients aged 35 years or older and followed for 2 years. Independent associations of stroke severity (as measured by National Ins ...[more]

PMID: 25817617

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Project description:Background and Purpose- Classification of stroke as cardioembolic in etiology can be challenging, particularly since the predominant cause, atrial fibrillation (AF), may not be present at the time of stroke. Efficient tools that discriminate cardioembolic from noncardioembolic strokes may improve care as anticoagulation is frequently indicated after cardioembolism. We sought to assess and quantify the discriminative power of AF risk as a classifier for cardioembolism in a real-world population of patients with acute ischemic stroke. Methods- We performed a cross-sectional analysis of a multi-institutional sample of patients with acute ischemic stroke. We systematically adjudicated stroke subtype and examined associations between AF risk using CHA2DS2-VASc, Cohorts for Heart and Aging Research in Genomic Epidemiology-AF score, and the recently developed Electronic Health Record-Based AF score, and cardioembolic stroke using logistic regression. We compared the ability of AF risk to discriminate cardioembolism by calculating C statistics and sensitivity/specificity cutoffs for cardioembolic stroke. Results- Of 1431 individuals with ischemic stroke (age, 65±15; 40% women), 323 (22.6%) had cardioembolism. AF risk was significantly associated with cardioembolism (CHA2DS2-VASc: odds ratio [OR] per SD, 1.69 [95% CI, 1.49-1.93]; Cohorts for Heart and Aging Research in Genomic Epidemiology-AF score: OR, 2.22 [95% CI, 1.90-2.60]; electronic Health Record-Based AF: OR, 2.55 [95% CI, 2.16-3.04]). Discrimination was greater for Cohorts for Heart and Aging Research in Genomic Epidemiology-AF score (C index, 0.695 [95% CI, 0.663-0.726]) and Electronic Health Record-Based AF score (0.713 [95% CI, 0.681-0.744]) versus CHA2DS2-VASc (C index, 0.651 [95% CI, 0.619-0.683]). Examination of AF scores across a range of thresholds indicated that AF risk may facilitate identification of individuals at low likelihood of cardioembolism (eg, negative likelihood ratios for Electronic Health Record-Based AF score ranged 0.31-0.10 at sensitivity thresholds 0.90-0.99). Conclusions- AF risk scores associate with cardioembolic stroke and exhibit moderate discrimination. Utilization of AF risk scores at the time of stroke may be most useful for identifying individuals at low probability of cardioembolism. Future analyses are warranted to assess whether stroke subtype classification can be enhanced to improve outcomes in undifferentiated stroke.

Project description:BackgroundNeurologic symptom severity and deterioration at 24 hours (h) predict long-term outcomes in patients with acute large vessel occlusion (LVO) stroke of the anterior circulation. We aimed to examine the association of baseline multiparametric CT imaging and clinical factors with the course of neurologic symptom severity in the first 24 h after endovascular treatment (EVT).MethodsPatients with LVO stroke of the anterior circulation were selected from a prospectively acquired consecutive cohort of patients who underwent multiparametric CT, including non-contrast CT, CT angiography and CT perfusion before EVT. The symptom severity was assessed on admission and after 24 h using the 42-point National Institutes of Health Stroke Scale (NIHSS). Clinical and imaging data were compared between patients with and without early neurological deterioration (END). END was defined as an increase in ≥4 points, and a significant clinical improvement as a decrease in ≥4 points, compared to NIHSS on admission. Multivariate regression analyses were used to determine independent associations of imaging and clinical parameters with NIHSS score increase or decrease in the first 24 h.ResultsA total of 211 patients were included, of whom 38 (18.0%) had an END. END was significantly associated with occlusion of the internal carotid artery (odds ratio (OR), 4.25; 95% CI, 1.90-9.47) and the carotid T (OR, 6.34; 95% CI, 2.56-15.71), clot burden score (OR, 0.79; 95% CI, 0.68-0.92) and total ischemic volume (OR, 1.01; 95% CI, 1.00-1.01). In a comprehensive multivariate analysis model including periprocedural parameters and complications after EVT, carotid T occlusion remained independently associated with END, next to reperfusion status and intracranial hemorrhage. Favorable reperfusion status and small ischemic core volume were associated with clinical improvement after 24 h.ConclusionsThe use of imaging parameters as a surrogate for early NIHSS progression in an acute LVO stroke after EVT reached limited performance with only carotid T occlusion as an independent predictor of END. Reperfusion status and early complications in terms of intracranial hemorrhage are critical factors that influence patient outcome in the acute stroke phase after EVT.

Project description:OBJECTIVE:To evaluate the safety and efficacy of induced hypertension in patients with acute ischemic stroke. METHODS:In this multicenter randomized clinical trial, patients with acute noncardioembolic ischemic stroke within 24 hours of onset who were ineligible for revascularization therapy and those with progressive stroke during hospitalization were randomly assigned (1:1) to the control and intervention groups. In the intervention group, phenylephrine was administered intravenously to increase systolic blood pressure (SBP) up to 200 mm Hg. The primary efficacy endpoint was early neurologic improvement (reduction in NIH Stroke Scale [NIHSS] score of ≥2 points during the first 7 days). The secondary efficacy endpoint was a modified Rankin Scale score of 0 to 2 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage/edema, myocardial infarction, and death. RESULTS:In the modified intention-to-treat analyses, 76 and 77 patients were included in the intervention and control groups, respectively. After adjustment for age and initial stroke severity, induced hypertension increased the occurrence of the primary (odds ratio 2.49, 95% confidence interval [CI] 1.25-4.96, p = 0.010) and secondary (odds ratio 2.97, 95% CI 1.32-6.68, p = 0.009) efficacy endpoints. Sixty-seven (88.2%) patients of the intervention group exhibited improvements in NIHSS scores of ≥2 points during induced hypertension (mean SBP 179·7 ± 19.1 mm Hg). Safety outcomes did not significantly differ between groups. CONCLUSION:Among patients with noncardioembolic stroke who were ineligible for revascularization therapy and those with progressive stroke, phenylephrine-induced hypertension was safe and resulted in early neurologic improvement and long-term functional independence. CLINICALTRIALSGOV IDENTIFIER:NCT01600235. CLASSIFICATION OF EVIDENCE:This study provides Class III evidence that for patients with acute ischemic stroke, therapeutic-induced hypertension increases the probability of early neurologic improvement.

Dataset Information

Neurologic symptom severity after a recent noncardioembolic stroke and recurrent vascular risk.

Publications

Neurologic symptom severity after a recent noncardioembolic stroke and recurrent vascular risk.

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