Cecilia Targa

Different vascular risk factor profiles in ischemic stroke subtypes: a study fromthe “Sagrat Cor Hospital of Barcelona Stroke Registry”

Objectives– To characterize the vascular risk factor profiles in different subtypes of ischemic stroke. Material and methods– The study population consisted of 1473 consecutive ischemic stroke patients collected in a prospective stroke registry. The prevalence of vascular risk factors in each stroke subtype was analyzed independently and in comparison with other subtypes of stroke pooled together by means of univariate analysis and logistic regression models. Results– Hypertension was present in 52% of patients followed by atrial fibrillation in 27% and diabetes in 20%. The pattern of risk factors associated with atherothrombotic stroke included chronic obstructive pulmonary disease (COPD) (odds ratio [OR]=2.63), hypertension (OR=2.55), diabetes (OR=2.26), transient ischemic attack (OR=1.61), and age (OR=1.03). Previous cerebral hemorrhage (OR=4.72), hypertension (OR=4.29), obesity (OR=2.45), and diabetes (OR=1.73) were strong predictors of lacunar stroke. In the case of cardioembolic stroke, atrial fibrillation (OR=22.24), valvular heart disease (OR=10.97), and female gender (OR=1.66) occurred more frequently among patients with this stroke subtype than among the other stroke subtypes combined. Conclusion– Different potentially modifiable vascular risk factor profiles were identified for each subtype of ischemic stroke, particularly COPD in the case of atherothrombotic stroke and previous cerebral hemorrhage and hypertension in the case of lacunar infarction.

Acute Stroke in Very Old People: Clinical Features and Predictors of In-Hospital Mortality

OBJECTIVES: To examine demographic characteristics, clinical features, neuroimaging data, and outcome of all acute stroke events occurring in individuals aged 85 years or older.

Acute Cerebrovascular Disease in Women

In 2,000 consecutive stroke patients collected in a prospective hospital-based stroke registry over a 10-year period, we assessed whether stroke in men and women was different in respect to vascular risk factors, clinical features and natural history. The frequency of the different variable in men and women was analyzed by means of univariate analysis and logistic regression models. Women accounted for 48% of the study population (n = 967) and were older than men (mean age 75 vs. 69 years, p < 0.001). In the age group of 85 years or older, stroke was more frequent in women than in men (69.8 vs. 30.2%, p < 0.001). Women showed a higher frequency of cardioembolic infarction and a lower occurrence of lacunar infarction and stroke of undetermined cause than men. In-hospital mortality (17.4 vs. 13.3%) and length of hospital stay (19.6 vs. 16.7 days) was significantly higher (p < 0.001) in women than in men. In the model based on demographic variables and cardiovascular risk factors, obesity, heart failure, atrial fibrillation and age were significant predictors of stroke in women, while intermittent claudication, ischemic heart disease, chronic obstructive pulmonary disease, cigarette smoking and alcohol abuse were predictors in male sex. Hypertension and limb weakness were predictors for stroke in women, and absence of neurological deficit at hospital discharge, lacunar syndrome and ataxia were predictors in men in the models based on all variables. Women differ from men in the distribution of risk factors and stroke subtype, stroke severity and outcome. Differences in stroke pathology and/or differences in functional anatomy or plasticity of the brain between sexes may account for these findings.

Trends in Risk Factors, Stroke Subtypes and Outcome

Background: Prospective stroke registries allow analyzing important aspects of the natural history of acute cerebrovascular events. Using the Sagrat Cor Hospital of Barcelona Stroke Registry, we aimed to determine trends in risk factors, stroke subtypes, prognosis and in-hospital mortality over 19 years in hospitalized stroke patients. Methods: The study population consisted of 2,416 first-ever stroke patients (ischemic stroke, n = 2,028; intracerebral hemorrhage, n = 334) included in the stroke registry up to December 31, 2004. Temporal trends in stroke patient characteristics for the periods 1986–1992, 1993–1998 and 1999–2004 were assessed. Results: Age was significantly different among the analyzed periods (p < 0.001), showing an increment in older patients throughout time. Hypertension (p = 0.001), diabetes (p = 0.004), ischemic heart disease (p = 0.002) and atrial fibrillation increased (p = 0.000) as opposed to heavy smoking (p = 0.000) and history of TIA (p = 0.025). The mortality rate and the length of hospital stay decreased (p = 0.001), whereas transfer to convalescent/rehabilitation units increased (p = 0.001). Conclusions: An improvement in acute-stroke management and possibly evolution of cerebrovascular risk factors is reflected by changes in the risk factors and outcome of first-ever stroke patients admitted to a stroke unit over a 19-year time span.

Clinical Features and Functional Outcome of Intracerebral Hemorrhage in Patients Aged 85 and Older

The importance of studies of older stroke victims is growing because of the changes in the age structure of Western populations. We determined demographic characteristics, clinical features, neuroimaging data, and outcome of acute spontaneous intracerebral hemorrhage occurring in people aged 85 and older.

Relevance of transient ischemic attack to early neurological recovery after nonlacunar ischemic stroke.

Background: We hypothesized that previous transient ischemic attack (TIA) had a favorable effect on early outcome after acute nonlacunar ischemic stroke. Methods: Data of 1,753 consecutive patients with ischemic stroke collected from a prospective hospital-based stroke registry were studied. A comparison was made of the groups with and without previous TIA. Favorable outcome included spontaneous neurological recovery or grades 0–2 of the modified Rankin scale at hospital discharge. Results: Previous TIA occurred in 55 (11.5%) of 484 patients with lacunar stroke and in 166 (13.1%) of 1,269 patients with nonlacunar stroke. The percentage of nonlacunar ischemic stroke patients with favorable outcome was 21.7% in those with a history of TIA compared to 15% without TIA (p < 0.03). In the lacunar stroke group, differences were not significant. In the multivariate analysis, TIA was an independent predictor of spontaneous in-hospital recovery. Conclusions: Prior TIA was associated with a favorable outcome in nonlacunar ischemic stroke, suggesting a neuroprotective effect of TIA possibly by inducing a phenomenon of ischemic tolerance allowing better recovery from a subsequent ischemic stroke.

Mild Cognitive Impairment after Lacunar Infarction: Voxel-Based Morphometry and Neuropsychological Assessment

Background: The aim of the present study was to investigate whether there were differences in neuroradiological features, including white-matter lesions and gray-matter volumes, between patients with lacunar infarction with and without mild cognitive impairment of the vascular type (MCI-V). Methods: A total of 40 patients with lacunar infarction were studied within 1 month after stroke. Results: MCI-V was found in 22 patients, who in comparison with patients without cognitive impairment were significantly older and had fewer years of formal education. MRI subcortical hyperintensities especially in the basal ganglia (putamen and thalamus) were significantly more frequent in the MCI-V group. In the voxel-based morphometric study, patients with MCI-V showed more atrophy bilaterally in the middle temporal gyrus, right and left frontal and posterior bilateral occipitoparietal regions including the posterior cingulate as well as in the cerebellum. A region of interest analysis restricted to the parahippocampi and hippocampi showed further reduced bilateral parahippocampal gyrus and right hippocampus volume reductions in this group of patients. Finally, the amount of white-matter lesions among MCI-V showed negative correlations with gray-matter volume in frontal and temporal areas as well as with the thalamus and mesencephalon. Conclusions: The present findings provide support for an anatomical substrate of the MCI entity in patients with lacunar infarction. Both gray- and white-matter changes seem to contribute to the cognitive impairment of such patients.

Site of bleeding and early outcome in primary intracerebral hemorrhage.

Objectives– To describe the influence of the site of the bleeding on clinical spectrum and early outcome of patients with acute spontaneous intracerebral hemorrhage (ICH). Material and methods– ICH was diagnosed in 229 (11%) of 2000 consecutive stroke patients included in a prospective stroke registry over a 10‐year period. Frequency of demographic variables, risk factors, clinical events, neuroimaging data, and early outcome (until hospital discharge) according to different sites of bleeding was assessed. Each topography of the bleeding (independent variable) was compared with the remaining ICH cases by means of logistic regression analysis. Results– In the multivariate analysis, sensory deficit was significantly associated with ICH in the thalamus; lacunar syndrome and hypertension with ICH in the internal capsule‐basal ganglia; seizures, non‐sudden stroke onset, and hypertension with lobar ICH; ataxia and sensory deficit with ICH in the cerebellum; cranial nerve palsy with ICH in the brainstem; and limb weakness, diabetes, and altered consciousness with multiple topographic involvement. The overall in‐hospital mortality rate was 31%, but this varied from 65% for multiple topographic involvement, 44% for intraventricular ICH, and 40% for ICH in the brainstem to 16% for ICH in the internal capsule‐basal ganglia. Conclusion– These data show the heterogeneous clinical profile of ICH, but they also suggest a difference in the clinical spectrum and in‐hospital mortality according to the site of bleeding.

Ischemic stroke of unusual cause: clinical features, etiology and outcome.

The clinical features, etiology and neurological outcome of ischemic stroke of unusual cause (ISUC) have rarely been reported. We retrospective reviewed all patients with this stroke subtype entered in the Sagrat Cor Hospital of Barcelona Stroke Registry, which includes data from 2000 consecutive first‐ever stroke patients admitted to the hospital between 1986 and 1995. Patients with previous ischemia and/or hemorrhagic stroke were excluded. Topographic, anamnestic, clinical and neuroimaging characteristics of ISUC were assessed. Predictors of this stroke subtype were determined by logistic regression analysis. Ischemic stroke of unusual etiology was diagnosed in 70 patients (32 men and 38 women), with a mean ± SD age of 52 ± 22.4 years. This stroke subtype accounted for 4.3% of all first‐ever strokes and 6% of all first‐ever brain infarcts. Etiologies included hematological disorders in 17 cases, infection in 11, migraine stroke in 10, cerebral infarction secondary to venous thrombosis in nine, primary inflammatory vascular conditions in six and miscellaneous causes in 17. In the multivariate analysis after excluding cerebral venous thrombosis (n = 9) and arterial dissection (n = 4), because of typical clinical and radiological features, independent predictors of ISUC included 45 years of age or less (odds ratio [OR] 14.8), seizures (OR 6.8), headache (OR 5.2), hemianopia (OR 2.6) and occipital lobe involvement (OR 3.0). Patients with ISUC presented a lower in‐hospital mortality rate (7.1% vs. 14.4%; P < 0.05), were more frequently symptom free at discharge (35.7% vs. 25.8%; P < 0.05) and experienced a longer mean length of hospital stay (23.7 days vs. 18.2 days; P = 0.06) than non‐ISUC patients. We conclude that ISUC is infrequent, etiologies are numerous and hematologic disorders are the most frequent cause. We emphasize the better prognosis and the need to distinguish it from other ischemic stroke subtypes which have a different treatment approach and outcome.

Pretreatment with statins improves early outcome in patients with first-ever ischaemic stroke: a pleiotropic effect of statins or a beneficial effect of hypercholesterolemia?

BackgroundData from different studies suggest a favourable association between pretreatment with statins or hypercholesterolemia and outcome after ischaemic stroke. We examined whether there were differences in in-hospital mortality according to the presence or absence of statin therapy in a large population of first-ever ischaemic stroke patients and assessed the influence of statins upon early death and spontaneous neurological recovery.MethodsIn 2,082 consecutive patients with first-ever ischaemic stroke collected from a prospective hospital-based stroke registry during a period of 19 years (1986-2004), statin use or hypercholesterolemia before stroke was documented in 381 patients. On the other hand, favourable outcome defined as grades 0-2 in the modified Rankin scale was recorded in 382 patients.ResultsEarly outcome was better in the presence of statin therapy or hypercholesterolemia (cholesterol levels were not measured) with significant differences between the groups with and without pretreatment with statins in in-hospital mortality (6% vs 13.3%, P = 0.001) and symptom-free (22% vs 17.5%, P = 0.025) and severe functional limitation (6.6% vs 11.5%, P = 0.002) at hospital discharge, as well as lower rates of infectious respiratory complications during hospitalization. In the logistic regression model, statin therapy was the only variable inversely associated with in-hospital death (odds ratio 0.57) and directly associated with favourable outcome (odds ratio 1.32).ConclusionsUse of statins or hypercholesterolemia before first-ever ischaemic stroke was associated with better early outcome with a reduced mortality during hospitalization and neurological disability at hospital discharge. However, statin therapy may increase the risk of intracerebral haemorrhage, particularly in the setting of thrombolysis.