Emili Comes

Predictive Factors of Early Seizures After Acute Cerebrovascular Disease

BACKGROUND AND PURPOSE Seizures within the first 48 hours of a first stroke or transient ischemic attack (TIA) are an independent prognostic factor for in-hospital mortality. The aim of this study was to determine predictive factors of early seizures in first-ever stroke patients. METHODS Data of 1220 first-ever stroke patients admitted consecutively to an acute stroke unit of a 450-bed teaching hospital between January 1986 and December 1993 were collected from a stroke registry. Demographic, anamnestic, clinical, neurological, and neuroimaging variables in the seizure and nonseizure group were compared using the t test and the chi 2 test. The independent predictive value of each variable on the development of early seizures was assessed with a logistic regression analysis. RESULTS Early epileptic seizures were diagnosed in 29 patients (2.4%). Seizures were significantly more frequent in patients with hemorrhagic stroke (4.3%) than in those with ischemic stroke (2%). Patients with seizures were significantly younger and significantly more likely to have acute confusional state, cortical involvement, large stroke, and involvement of the parietal, frontal, occipital, and temporal lobes than patients without seizures. The in-hospital mortality rate was 37.9% in the seizure group and 14.4% in the nonseizure group (P < .0005). After multivariate analysis, only cortical involvement (odds ratio of 6.01) and acute agitated confusional state (odds ratio of 4.44) were independent clinical factors for developing epileptic seizures. CONCLUSIONS Cortical involvement in the neuroimaging studies and agitated acute confusional state at the onset of stroke were independent predictive factors of early seizures in first-ever stroke patients. The efficacy of anticonvulsant drugs in the prophylactic control of seizures should be assessed in prospective, randomized, double-blind clinical trials conducted in the subgroup of patients with the highest risk of developing epileptic seizures.

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.

Prognostic Value of Very Early Seizures for In-Hospital Mortality in Atherothrombotic Infarction

We studied the influence of very early seizures (within 48 h of stroke onset) on in-hospital mortality in a cohort of 452 consecutive patients with atherothrombotic infarction. These patients were selected from 2,000 consecutive acute stroke patients registered in a prospective hospital-based stroke registry in Barcelona, Spain. A comparison of data between the nonseizure (n = 442) and seizure (n = 10) groups was made. Predictors of very early seizures were assessed by multivariate analysis. The in-hospital mortality rate was significantly higher in atherothrombotic stroke patients with very early seizures than in those without seizures (70 vs. 19.5%, p < 0.001). Independent predictors of in-hospital mortality included very early seizures, congestive heart failure, atrial fibrillation, 85 years of age or older, altered consciousness, dizziness, parietal and pons involvement, and respiratory and cardiac complications. After multivariate analysis, atherothrombotic infarction of occipital topography and decreased consciousness appeared to be independent predictors of atherothrombotic stroke with very early seizures. Very early seizures constitute an important risk factor for in-hospital mortality after atherothrombotic stroke.

Clinical study of 99 patients with pure sensory stroke

ObjectiveWe report a clinical description of pure sensory stroke based on data collected from a prospective acute stroke registry.MethodsFrom 2500 acute stroke patients included in a hospital-based prospective stroke registry over a 12-year period, 99 were identified as having pure sensory stroke.ResultsPure sensory stroke accounted for 4.7% of all acute stroke patients, 5.4% of acute ischemic stroke, and 17.4% of lacunar syndromes. Complete hemisensory syndrome was present in 80 patients and incomplete hemisensory syndrome in 19 (cheiro-oral syndrome 12, cheiro-oral-pedal 6, isolated oral syndrome 1). The lacunar hypothesis was fulfilled in 88% of patients. Atherothrombotic infarction occurred in 8 patients, intracerebral hemorrhage in 3, and stroke of undetermined cause in 1. Hemorrhagic pure sensory stroke was diagnosed in 1% of all cases of hemorrhagic stroke (n=270) in the database. Outcome was good (in-hospital mortality 0%, symptom-free at discharge 41.5 %). After multivariate analysis, absence of disability at discharge, hypertension, diabetes, hyperlipidemia, and thalamic (56.5 %) and corona radiata (4 %) locations were clinical and topographic variables significantly associated with pure sensory stroke.ConclusionsPure sensory stroke is an infrequent cerebrovascular syndrome, in which the lacunar hypothesis is supported. Most patients had thalamic lacunar infarction. Incomplete hemisensory syndromes were also caused by a lacunar infarct in 84% of patients. Hemorrhagic pure sensory stroke accounted only for 3% of the cases. The prognosis is good with striking similarity to other lacunar strokes. There are important differences between pure sensory stroke and nonlacunar strokes.

Recurrent lacunar infarction following a previous lacunar stroke: a clinical study of 122 patients

Objective: To determine clinical variables related to recurrent lacunar infarction following a previous lacunar stroke. Methods: A total of 122 out of 733 consecutive patients with lacunar infarction collected from a hospital based registry between 1986 and 2004 were readmitted because of a recurrent lacunar infarction. In a subset of 59 patients, cognition was assessed using the Mini-Mental State Examination (MMSE). Predictors of lacunar infarction recurrence were assessed by logistic regression analysis. Results: First lacunar infarction recurrence occurred in 101 patients (83%) and multiple recurrences in 21. The mean time between first ever lacunar infarction and recurrent lacunes was 58.3 months (range 2–240). In the subset of 59 patients in whom cognition was studied, cognitive impairment, defined as an MMSE score <24, was detected in 16% (8/49) of patients with first lacunar infarction recurrence and in 40% (4/10) of those with multiple lacunar infarction recurrences. In the multivariate analysis, hypertension (odds ratio 2.01, 95% CI 1.23 to 3.30) and diabetes (odds ratio 1.62, 95% CI 1.07 to 2.46) were significant predictors of lacunar stroke recurrence, whereas hyperlipidaemia was inversely associated (odds ratio 0.52, 95% CI 0.30 to 0.90). Conclusions: Hypertension and diabetes were significant factors related to recurrent lacunar infarction. Hyperlipidaemia appeared to have a protective role. Cognitive impairment was a frequent finding in patients with multiple lacunar infarction recurrences.

Clinical study of 35 patients with dysarthria-clumsy hand syndrome

Objectives: Although dysarthria-clumsy hand syndrome (DCHS) is a well known and infrequent lacunar syndrome, there are few data regarding the spectrum of associated clinical characteristics, anatomical site of lesion, and aetiopathogenetic mechanisms. We report a clinical description of this subtype of lacunar stroke based on data collected from a prospective acute stroke registry. Methods: From 2500 acute stroke patients included in a hospital based prospective stroke registry over a 12-year period, 35 patients were identified as having DCHS. Results: DCHS accounted for 1.6% of all acute stroke patients (35/2110), 1.9% of acute ischaemic stroke (35/1840), and 6.1% of lacunar syndromes (35/570) admitted consecutively to a neurology department and included in the stroke registry over this period. The results supported the lacunar hypothesis in 94.3% of patients (n = 33). Atherothrombotic and cardioembolic infarction occurred in only one patient each (2.9%). No patient with DCHS had an intracerebral haemorrhage. Outcome was good (mortality in hospital 0%, symptom free at discharge 45.7%). After multivariate analysis, absence of limitation at discharge, limb weakness but not cerebellar-type ataxia, and internal capsule (40%), pons (17%), and corona radiata (8.6%) location were significantly associated with DCHS. Conclusions: DCHS is a rare cerebrovascular syndrome, and supports the criteria of the lacunar hypothesis. The majority of patients in this study had internal capsule infarcts. The prognosis is good with striking similarity compared with other types of lacunar strokes. There are important differences between DCHS and non-lacunar strokes. Internal capsule and pons are the most frequent cerebral sites.

Predicting spontaneous early neurological recovery after acute ischemic stroke

We assessed predictors of spontaneous early neurological recovery after acute ischemic stroke by means of multivariate analysis in a cohort of 1473 consecutive patients treated at one academic center. At hospital discharge, spontaneous neurological improvement or good outcome was defined as grades 0–2 of the Rankin scale, and poor outcome (no improvement or in‐hospital death) as grades 3–5. Spontaneous recovery of neurological deficit at the time of discharge from the hospital was observed in 16% of patients with cerebral infarction (n = 238). Dysarthria‐clumsy hand syndrome improved in 44% of patients and was the only variable significantly associated with in‐hospital functional recovery in three logistic regression models that in addition to lacunar syndromes, included demographic variables, cardiovascular risk factors, and clinical variables [odds ratio (OR) 2.56], neuroimaging findings (OR 2.48), and outcome data (OR 2.39), respectively. Clinical factors related to severity of infarction available at stroke onset have a predominant influence upon in‐hospital outcome and may help clinicians to assess prognosis more accurately. Our work gives a contribution into prognostic factors after acute ischemic stroke. With regard to patterns of stroke, dysarthria‐clumsy hand syndrome was a significant predictor of spontaneous in‐hospital recovery in ischemic stroke patients.

Importance of Cardiovascular Risk Profile for In-Hospital Mortality Due to Cerebral Infarction

INTRODUCTION AND OBJECTIVES To investigate cardiovascular risk profiles and their prognostic implications in patients with different subtypes of cerebral infarction. METHODS The study involved the retrospective analysis of data from a hospital stroke registry on 2704 consecutive CI patients who were admitted between 1986 and 2004. Of the 2704 strokes recorded, 770 were classified as thrombotic, 763 as cardioembolic, 733 as lacunar, 324 as undetermined and 114 as atypical. Multivariate analysis was used to compare cardiovascular risk profiles in each subtype and their influence on inhospital mortality. RESULTS Arterial hypertension (AH) was present in 55.5%, atrial fibrillation (AF) in 29.8%, and diabetes mellitus in 23.4%. The in-hospital mortality rate was 12.9%, and in-hospital mortality was independently associated with AF (odds ratio [OR]=2.33; 95% confidence interval [CI], 1.84-2.96), and heart failure (HF) (OR=1.96; 95% CI, 1.33-2.89). In patients with thrombotic stroke, the cardiovascular risk factors associated with in-hospital mortality were HF (OR=2.87; 95% CI, 1.45-5.71), AF (OR=1.80; 95% CI, 1.09-2.96) and age (OR=1.06; 95% CI, 1.04-1.08). In patients with cardioembolic stroke, they were peripheral vascular disease (OR=2.18; 95% CI, 1.17-4.05), previous cerebral infarction (OR=1.75; 95% CI, 1.16-2.63), HF (OR=1.71; 95% CI, 1.01-2.90), and age (OR=1.06; 95% CI, 1.04-1.08). In those with undetermined stroke, they were AH (OR=3.68; 95% CI, 1.78-7.62) and age (OR=1.05; 95% CI, 1.01-1.09). CONCLUSIONS Each cerebral infarction etiologic subtype was associated with its own cardiovascular risk profile. Consequently, the cardiovascular risk factors associated with mortality were also different for each ischemic stroke subtype.

Stroke-Related Headache: A Clinical Study in Lacunar Infarction

Objective.—To describe the characteristics of headache related to lacunar stroke based on data collected from a prospective hospital‐based stroke registry over a 12‐year period. Demographics, clinical variables, and prognostic features of lacunar stroke in patients with and without headache are compared.

Clinical Implications of Headache in Lacunar Stroke: Relevance of Site of Infarct

Objective.—To assess whether the infarction topography influenced upon the incidence of headache and the likelihood of neurological recovery in lacunar infarction.