Gilbert Fortunato

Long-term Improvement in Outcome After Intracerebral Hemorrhage in Patients Treated with Statins

BACKGROUND Intracerebral hemorrhage (ICH) is a severe type of stroke for which there is currently no specific medical therapy. We hypothesized that statins reduce immediate inflammatory injury and improve long-term recovery from increased neurogenesis and angiogenesis. We conducted a large retrospective cohort study to assess the influence of statin therapy on patient death and disability at 12 months after ICH. METHODS This was a retrospective analysis of a prospectively collected database at a tertiary care medical center. Patients were grouped based on statin use, and poor outcome was assessed as dead or alive with dependency (modified Barthel Index≤14). RESULTS We compared outcomes in 190 patients exposed to statins to 236 patients who were not exposed to statins. Univariate analysis found that statin use was associated with decreased mortality in-hospital and at 12 months (P=.001). Multivariable analysis found that statin use was associated with a decreased odds of death or disability at 12 months after ICH (odds ratio 0.44; 95% confidence interval 0.21-0.95). CONCLUSIONS Statin use is associated with improved long-term outcome at 12 months after ICH. This finding supports previous clinical studies that have shown the short-term benefits of statin therapy. In addition, this study correlates with animal studies supporting the possible long-term recovery benefits of statins.

Prestroke living situation and depression contribute to initial stroke severity and stroke recovery

Substantial evidence from both experimental and clinical studies has demonstrated that social isolation can increase stroke incidence and impair recovery. Social isolation leads to higher rates of recurrent stroke but is often not reported as a risk factor. We examined prospectively collected stroke center database variables, which included prestroke living situation, to determine if social isolation could be determined from existing data using living arrangement as a proxy. Patients were categorized into 4 groups hypothesized to represent increasing levels of social isolation: living with spouse, living with family, living alone with visiting services, and living alone. Initial stroke severity and recovery were measured using the National Institutes of Health Stroke Scale and Barthel Index, respectively. A multivariate model was used to determine the relationship among prestroke living situation, stroke severity, and functional outcome. Patients living alone had less severe strokes on admission and better recovery at 3 months compared with the other cohorts. Patients living alone or those who lived with a spouse had less severe strokes on presentation and better recovery at both 3 and 12 months after stroke compared with the other cohorts. However, on detailed examination, it was found that these patients also had significantly higher prestroke function. Pre-existing depression was significantly higher in women, and depressed patients had poorer outcomes 3 months after stroke. Information regarding isolation is notably absent from most large stroke databases. A more comprehensive evaluation of social interaction should be obtained to more accurately measure social isolation.

Sex differences and the role of IL-10 in ischemic stroke recovery.

Females experience poorer recovery after ischemic stroke compared to males, even after controlling for age and stroke severity. IL-10 is an anti-inflammatory cytokine produced by T regulatory cells and Th2 CD4+ helper T cells. In ischemic stroke, an excessive IL-10 response contributes to post-stroke immunosuppression, which worsens outcomes. However, it is unknown if sex differences exist in IL-10 levels after ischemic stroke. In this study, we found that higher levels of IL-10 were associated with poor acute and long-term outcomes after ischemic stroke in female patients but not in males. After controlling for confounders, IL-10 was not an independent predictor of functional outcomes. This suggests that higher serum IL-10 levels may reflect factors that interact with sex such as age and stroke severity.

β-Blockers associated with no class-specific survival benefit in acute intracerebral hemorrhage.

OBJECTIVES Despite the high mortality, there is currently no specific treatment for intracerebral hemorrhage (ICH). Research investigating optimum degree of blood pressure control in patients presenting with ICH and hypertension is ongoing. However, there is limited understanding of the potential benefits of specific classes of antihypertensive therapy. β-Adrenergic antagonists may provide neuroprotection from inflammation-induced injury by inhibiting sympathetic nervous system mediated immune activation. We examined mortality in ICH patients receiving β-adrenergic antagonists to determine whether this class of antihypertensive therapy was associated with improved survival. METHODS A retrospective analysis of a large, prospectively collected database of patients presenting with acute ICH was performed. Patients were grouped by inpatient β-blocker treatment to determine an effect on mortality during the inpatient stay and at 3 months of follow-up. Additional analysis was conducted comparing β-blocker therapy to any other antihypertensive treatment to determine a class-specific association of β-blocker treatment with mortality. RESULTS The study population included 426 patients with acute, spontaneous ICH. Inpatient β-blocker use was independently associated with decreased rates of inpatient death and mortality at 3 months of follow-up. However, univariate and multivariable analyses comparing β-blocker use to other antihypertensives failed to show any class-specific reduction in mortality at either time point. DISCUSSION Our study demonstrates that the improvement seen in patients treated with β-adrenergic antagonists is not an effect unique to this class. This supports ongoing trials to determine optimum levels of blood pressure control using multiple classes of antihypertensives.

Stroke Simulation Improves Acute Stroke Management: A Systems-Based Practice Experience

Background Literature on the effectiveness of simulation-based medical education programs for caring for acute ischemic stroke (AIS) patients is limited. Objective To improve coordination and door-to-needle (DTN) time for AIS care, we implemented a stroke simulation training program for neurology residents and nursing staff in a comprehensive stroke center. Methods Acute stroke simulation training was implemented for first-year neurology residents in July 2011. Simulations were standardized using trained live actors, who portrayed stroke vignettes in the presence of a board-certified vascular neurologist. A debriefing of each residents performance followed the training. The hospital stroke registry was also used for retrospective analysis. The study population was defined as all patients treated with intravenous tissue plasminogen activator for AIS between October 2008 and September 2014. Results We identified 448 patients meeting inclusion criteria. Simulation training independently predicted reduction in DTN time by 9.64 minutes (95% confidence interval [CI] -15.28 to -4.01, P = .001) after controlling for age, night/day shift, work week versus weekend, and blood pressure at presentation (> 185/110). Systolic blood pressure higher than 185 was associated with a 14.28-minute increase in DTN time (95% CI 3.36-25.19, P = .011). Other covariates were not associated with any significant change in DTN time. Conclusions Integration of simulation based-medical education for AIS was associated with a 9.64-minute reduction in DTN time.

High Mortality among 30-Day Readmission after Stroke: Predictors and Etiologies of Readmission

Background Although some risk factors for stroke readmission have been reported, the mortality risk is unclear. We sought to evaluate etiologies and predictors of 30-day readmissions and determine the associated mortality risk. Methods This is a retrospective case–control study evaluating 1,544 patients admitted for stroke (hemorrhagic, ischemic, or TIA) from January 2013 to December 2014. Of these, 134 patients readmitted within 30 days were identified as cases; 1,418 other patients, with no readmissions were identified as controls. Patients readmitted for hospice or elective surgery were excluded. An additional 248 patients deceased on index admission were included for only a comparison of mortality rates. Factors explored included socio-demographic characteristics, clinical comorbidities, stroke characteristics, and length of stay. Chi-square test of proportions and multivariable logistic regression were used to identify independent predictors of 30-day stroke readmissions. Mortality rates were compared for index admission and readmission and among readmission diagnoses. Results Among the 1,544 patients in the main analysis, 67% of index stroke admissions were ischemic, 22% hemorrhagic, and 11% TIA. The 30-day readmission rate was 8.7%. The most common etiologies for readmission were infection (30%), recurrent stroke and TIA (20%), and cardiac complications (14%). Significantly higher proportion of those readmitted for recurrent strokes and TIAs presented within the first week (p = 0.039) and had a shorter index admission length of stay (p = 0.027). Risk factors for 30-day readmission included age >75 (p = 0.02), living in a facility prior to index stroke (p = 0.01), history of prior stroke (p = 0.03), diabetes (p = 0.03), chronic heart failure (p ≤ 0.001), atrial fibrillation (p = 0.03), index admission to non-neurology service (p < 0.01), and discharge to other than home (p < 0.01). On multivariate analysis, index admission to a non-neurology service was an independent predictor of 30-day readmission (p ≤ 0.01). The mortality after a within 30-day readmission after stroke was higher than index admission (36.6 vs. 13.8% p ≤ 0.001) (OR 3.6 95% CI 2.5–5.3). Among those readmitted, mortality was significantly higher for those admitted for a recurrent stroke (p = 0.006). Conclusion Approximately one-third of 30-day readmissions were infection related and one-fifth returned with recurrent stroke or TIA. Index admission to non-neurology service was an independent risk factor of 30-day readmissions. The mortality rate for 30-day readmission after stroke is more than 2.5 times greater than index admissions and highest among those readmitted for recurrent stroke. Identifying high-risk patients for readmission, ensuring appropriate level of service, and early outpatient follow-up may help reduce 30-day readmission and the high associated risk of mortality.